Healthcare Provider Details

I. General information

NPI: 1891803490
Provider Name (Legal Business Name): HERITAGE OF BRIDGEPORT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 06/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 O ST
BRIDGEPORT NE
69336-4045
US

IV. Provider business mailing address

505 O STREET
BRIDGEPORT NE
69336-4045
US

V. Phone/Fax

Practice location:
  • Phone: 308-262-0725
  • Fax: 308-262-0470
Mailing address:
  • Phone: 308-262-0725
  • Fax: 308-262-0470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number544002
License Number StateNE

VIII. Authorized Official

Name: MR. JACK DEAN VETTER
Title or Position: PRESIDENT
Credential:
Phone: 402-895-3932