Basic Information
| Provider Information | |||||||||
| NPI: | 1114469046 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PMG OPCO-BRIDGEPORT LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE RESIDENCES AT SENIOR CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2106 15TH ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764262073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406836307 | ||||||||
| FaxNumber: | 9406835307 | ||||||||
| Practice Location | |||||||||
| Address1: | 2106 15TH ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764262073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406836307 | ||||||||
| FaxNumber: | 9406835307 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2016 | ||||||||
| LastUpdateDate: | 11/09/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOULWARE | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3186589977 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | TX | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.