Provider Demographics
NPI:1891803490
Name:HERITAGE OF BRIDGEPORT, INC
Entity Type:Organization
Organization Name:HERITAGE OF BRIDGEPORT, INC
Other - Org Name:HERITAGE OF BRIDGEPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:VETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-895-3932
Mailing Address - Street 1:505 O STREET
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:NE
Mailing Address - Zip Code:69336-4045
Mailing Address - Country:US
Mailing Address - Phone:308-262-0725
Mailing Address - Fax:308-262-0470
Practice Address - Street 1:505 O ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:NE
Practice Address - Zip Code:69336-4045
Practice Address - Country:US
Practice Address - Phone:308-262-0725
Practice Address - Fax:308-262-0470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE544002314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE=========00Medicaid
NE285224Medicare Oscar/Certification
NE0481450001Medicare ID - Type UnspecifiedMEDICARE PART B SUPPLIER
NE28D0456498Medicare ID - Type UnspecifiedMEDICARE CLIA WAIVER #