Provider Demographics
NPI:1205099231
Name:BRIDGEWELL
Entity type:Organization
Organization Name:BRIDGEWELL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-859-2142
Mailing Address - Street 1:410 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OSAKIS
Mailing Address - State:MN
Mailing Address - Zip Code:56360-8243
Mailing Address - Country:US
Mailing Address - Phone:320-859-2142
Mailing Address - Fax:320-859-6292
Practice Address - Street 1:410 W MAIN ST
Practice Address - Street 2:
Practice Address - City:OSAKIS
Practice Address - State:MN
Practice Address - Zip Code:56360-8243
Practice Address - Country:US
Practice Address - Phone:320-859-2142
Practice Address - Fax:320-859-6292
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY MEMORIAL HOME AT OSAKIS MINNESOTA INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-09
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN339876310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility