1154610772 NPI number — BRIDAN HEALTHCARE, LLC

Table of content: (NPI 1154610772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154610772 NPI number — BRIDAN HEALTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDAN HEALTHCARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154610772
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
64 BENTWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTAMPTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08060-5640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-410-7942
Provider Business Mailing Address Fax Number:
609-871-4002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
64 BENTWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTAMPTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08060-5640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-410-7942
Provider Business Practice Location Address Fax Number:
609-871-4002
Provider Enumeration Date:
04/04/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FULTON
Authorized Official First Name:
VALERIE
Authorized Official Middle Name:
DAWN
Authorized Official Title or Position:
NURSE PRACTITIONER
Authorized Official Telephone Number:
609-410-7942

Provider Taxonomy Codes

  • Taxonomy code: 363LW0102X , with the licence number:  SP010784 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LW0102X , with the licence number: 26NN10281700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)