Healthcare Provider Details

I. General information

NPI: 1316655871
Provider Name (Legal Business Name): BRIDGEWATER BAY HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 MEADOW LARK DR
SAN DIEGO CA
92123-2710
US

IV. Provider business mailing address

2828 MEADOW LARK DR
SAN DIEGO CA
92123-2710
US

V. Phone/Fax

Practice location:
  • Phone: 858-798-5700
  • Fax:
Mailing address:
  • Phone: 858-798-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MYRNA ALDONZA DE GUZMAN
Title or Position: CORPORATE CONTROLLER
Credential:
Phone: 760-331-3177