MEDICARE: BRIDGEWOOD BRYAN, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311500000X	Alzheimer Center (Dementia Center)		TX
2	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1861759250
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEWOOD BRYAN, LLC

Provider Business Mailing Address
First Line	:	4235 BOONVILLE RD
Second Line	:
City	:	BRYAN
State	:	TX
Zip	:	77802-3641
Country	:	US
Telephone Number	:	979-731-1300
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 E PARKWOOD AVE STE 100
Second Line	:
City	:	FRIENDSWOOD
State	:	TX
Zip	:	77546-5152
Country	:	US
Telephone Number	:	281-996-0101
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. JAMES D. GRAY
Credential	:
Telephone Number	:	713-623-6767

Provider Enumeration Date	:	04/23/2012
Last Update Date	:	04/23/2012

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