Provider Demographics
NPI:1225577505
Name:BRIDGEWATER PARK LLC
Entity Type:Organization
Organization Name:BRIDGEWATER PARK LLC
Other - Org Name:BRIDGEWATER PARK HEALTH & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CULLEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-664-5400
Mailing Address - Street 1:1800 N WABASH RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1300
Mailing Address - Country:US
Mailing Address - Phone:765-664-5400
Mailing Address - Fax:
Practice Address - Street 1:9280 SW 81ST CT
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34481
Practice Address - Country:US
Practice Address - Phone:352-509-5201
Practice Address - Fax:352-861-4255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-20
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0229220-00Medicaid