Provider Demographics
NPI:1255427415
Name:BRIDGEPORT SENIOR LIVING, LLC
Entity type:Organization
Organization Name:BRIDGEPORT SENIOR LIVING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MGR. BRIDGEPORT SENIOR LIVING, LLC
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-375-9016
Mailing Address - Street 1:RR 4 BOX 17
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9509
Mailing Address - Country:US
Mailing Address - Phone:304-842-4135
Mailing Address - Fax:
Practice Address - Street 1:RR 4 BOX 17
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-9509
Practice Address - Country:US
Practice Address - Phone:304-842-4135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV7313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility