Basic Information
Provider Information | |||||||||
NPI: | 1043235716 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BRIDGEWAY ESTATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 103 12TH ST. NE | ||||||||
Address2: |   | ||||||||
City: | LITTLE FALLS | ||||||||
State: | MN | ||||||||
PostalCode: | 56345 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3206322089 | ||||||||
FaxNumber: | 3206322097 | ||||||||
Practice Location | |||||||||
Address1: | 103 12TH ST. NE | ||||||||
Address2: |   | ||||||||
City: | LITTLE FALLS | ||||||||
State: | MN | ||||||||
PostalCode: | 56345 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3206322089 | ||||||||
FaxNumber: | 3206322097 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOESTER | ||||||||
AuthorizedOfficialFirstName: | MERLIN | ||||||||
AuthorizedOfficialMiddleName: | ARTHUR | ||||||||
AuthorizedOfficialTitleorPosition: | BOARD OF DIRECTORS, PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3206329211 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 330186 | MN | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
ID Information
ID | Type | State | Issuer | Description | 4980473 | 01 | MN | MEDICA | OTHER |