Provider Demographics
NPI:1124431762
Name:BRIDGEPORT SENIOR LIVING - PORT ISLE LLC
Entity type:Organization
Organization Name:BRIDGEPORT SENIOR LIVING - PORT ISLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GALBASINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-760-3649
Mailing Address - Street 1:13506 SUMMERPORT VILLAGE PKWY
Mailing Address - Street 2:#129
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-7366
Mailing Address - Country:US
Mailing Address - Phone:407-760-3649
Mailing Address - Fax:
Practice Address - Street 1:13506 SUMMERPORT VILLAGE PKWY
Practice Address - Street 2:#129
Practice Address - City:WINDERMERE
Practice Address - State:FL
Practice Address - Zip Code:34786-7366
Practice Address - Country:US
Practice Address - Phone:407-760-3649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL123723747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty