Basic Information
| Provider Information | |||||||||
| NPI: | 1336524586 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRIDGEPORT HEALTH CARE CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 532 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253220532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043441623 | ||||||||
| FaxNumber: | 3045569165 | ||||||||
| Practice Location | |||||||||
| Address1: | RT 4 BOX 17 | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263309509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048424195 | ||||||||
| FaxNumber: | 3048424398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2015 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3043441623 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
No ID Information.