Healthcare Provider Details

I. General information

NPI: 1225577505
Provider Name (Legal Business Name): BRIDGEWATER PARK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2017
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9280 SW 81ST CT
OCALA FL
34481
US

IV. Provider business mailing address

1800 N WABASH RD
MARION IN
46952-1300
US

V. Phone/Fax

Practice location:
  • Phone: 352-509-5201
  • Fax: 352-861-4255
Mailing address:
  • Phone: 765-664-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. CULLEN S GIBSON
Title or Position: VICE PRESIDENT
Credential:
Phone: 765-664-5400