1285803148 NPI number — BRIDGEPORT ESSENTIAL PRACTICES, LLC

Table of content: (NPI 1285803148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285803148 NPI number — BRIDGEPORT ESSENTIAL PRACTICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDGEPORT ESSENTIAL PRACTICES, 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:
BRIDGEPORT HEALTH CARE CENTER
Provider Other Organization Name Type Code:
3
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:
1285803148
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 W CATES ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRIDGEPORT
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76426-2709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-683-5183
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 W CATES ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76426-2709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-683-5183
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WATT
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
OPERATING MANAGER
Authorized Official Telephone Number:
731-267-2861

Provider Taxonomy Codes

  • Taxonomy code: 3140N1450X , with the licence number:  004054 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com