Provider Demographics
NPI:1154023224
Name:BRIDGEPORT SENIOR LIVING - PORT MAITLAND LLC
Entity type:Organization
Organization Name:BRIDGEPORT SENIOR LIVING - PORT MAITLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTHONY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-810-1344
Mailing Address - Street 1:404 SPRING VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-5845
Mailing Address - Country:US
Mailing Address - Phone:407-810-1344
Mailing Address - Fax:
Practice Address - Street 1:955 STONEWOOD LN
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-3238
Practice Address - Country:US
Practice Address - Phone:407-810-1344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility