Provider Demographics
NPI:1003814948
Name:2028 BRIDGEPORT AVENUE OPERATING COMPANY II LLC
Entity type:Organization
Organization Name:2028 BRIDGEPORT AVENUE OPERATING COMPANY II LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VP
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRESLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-242-4004
Mailing Address - Street 1:2028 BRIDGEPORT AVE
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-4613
Mailing Address - Country:US
Mailing Address - Phone:203-887-0371
Mailing Address - Fax:203-882-8760
Practice Address - Street 1:2028 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-4613
Practice Address - Country:US
Practice Address - Phone:203-887-0371
Practice Address - Fax:203-882-8760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2281314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE075213Medicare ID - Type Unspecified