1750797312 NPI number — BRIDGETON OPERATIONS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750797312 NPI number — BRIDGETON OPERATIONS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDGETON OPERATIONS, 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:
6
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:
1750797312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3001 KEITH ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37312-3713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-473-5751
Provider Business Mailing Address Fax Number:
423-339-8342

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12145 BRIDGETON SQ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGETON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63044-2616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-298-7444
Provider Business Practice Location Address Fax Number:
314-298-7456
Provider Enumeration Date:
07/03/2014

Additional Information

Authorized Official

Authorized Official Last Name:
CROSS
Authorized Official First Name:
CINDY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
423-473-5867

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  041644 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102232501 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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