Provider Demographics
NPI:1114469046
Name:PMG OPCO-BRIDGEPORT LLC
Entity Type:Organization
Organization Name:PMG OPCO-BRIDGEPORT LLC
Other - Org Name:THE RESIDENCES AT SENIOR CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:B
Authorized Official - Last Name:BOULWARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-658-9977
Mailing Address - Street 1:2106 15TH ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:TX
Mailing Address - Zip Code:76426-2073
Mailing Address - Country:US
Mailing Address - Phone:940-683-6307
Mailing Address - Fax:940-683-5307
Practice Address - Street 1:2106 15TH ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:TX
Practice Address - Zip Code:76426-2073
Practice Address - Country:US
Practice Address - Phone:940-683-6307
Practice Address - Fax:940-683-5307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility