Provider Demographics
NPI:1669065777
Name:1169 BRYDEN PLACE LLC
Entity type:Organization
Organization Name:1169 BRYDEN PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:ANN MOUTON
Authorized Official - Last Name:MONROE
Authorized Official - Suffix:
Authorized Official - Credentials:LPN, CPD, CDAL, PCHA
Authorized Official - Phone:614-927-2700
Mailing Address - Street 1:1169 BRYDEN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-1979
Mailing Address - Country:US
Mailing Address - Phone:614-927-2700
Mailing Address - Fax:
Practice Address - Street 1:1169 BRYDEN RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-1979
Practice Address - Country:US
Practice Address - Phone:614-927-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility