Provider Demographics
NPI:1932663994
Name:BRIDGEWATER AVONDALE OPERATIONS, LLC
Entity Type:Organization
Organization Name:BRIDGEWATER AVONDALE OPERATIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:INGE
Authorized Official - Middle Name:G
Authorized Official - Last Name:DURAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-544-3195
Mailing Address - Street 1:14650 N 78TH WAY, BLDG B
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260
Mailing Address - Country:US
Mailing Address - Phone:602-544-3195
Mailing Address - Fax:602-533-7574
Practice Address - Street 1:295 E VAN BUREN STREET
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323
Practice Address - Country:US
Practice Address - Phone:602-603-8200
Practice Address - Fax:602-533-7574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAL10996COtherDEPT OF HEALTH SERVICES