Provider Demographics
NPI:1851811608
Name:BRIDGEWATER PARK ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:BRIDGEWATER PARK ASSISTED LIVING LLC
Other - Org Name:BRIDGEWATER PARK ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
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:765-664-5403
Practice Address - Street 1:9174 SW 81ST CT
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34481-7846
Practice Address - Country:US
Practice Address - Phone:352-816-0254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-22
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility