Provider Demographics
NPI:1336524586
Name:BRIDGEPORT HEALTH CARE CENTER, LLC
Entity Type:Organization
Organization Name:BRIDGEPORT HEALTH CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:R
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-344-1623
Mailing Address - Street 1:PO BOX 532
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25322-0532
Mailing Address - Country:US
Mailing Address - Phone:304-344-1623
Mailing Address - Fax:304-556-9165
Practice Address - Street 1:RT 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:304-842-4195
Practice Address - Fax:304-842-4398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility