Basic Information
| Provider Information | |||||||||
| NPI: | 1336701242 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRIDGETOWN HEALTH CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 S HIGH ST STE 770 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432153450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144611156 | ||||||||
| FaxNumber: | 6144617168 | ||||||||
| Practice Location | |||||||||
| Address1: | 4307 BRIDGETOWN RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452114427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135988000 | ||||||||
| FaxNumber: | 5135747424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2019 | ||||||||
| LastUpdateDate: | 07/01/2019 | ||||||||
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| AuthorizedOfficialLastName: | WEBSTER | ||||||||
| AuthorizedOfficialFirstName: | GEOFFREY | ||||||||
| AuthorizedOfficialMiddleName: | EVERETT | ||||||||
| AuthorizedOfficialTitleorPosition: | COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 6144611156 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | ESQ. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 2842N | 01 | OH | LICENSE | OTHER |