Healthcare Provider Details

I. General information

NPI: 1992013692
Provider Name (Legal Business Name): BRIDGEPORT ISD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2107 15TH ST
BRIDGEPORT TX
76426-2052
US

IV. Provider business mailing address

2107 15TH ST
BRIDGEPORT TX
76426-2052
US

V. Phone/Fax

Practice location:
  • Phone: 940-683-8361
  • Fax: 940-683-5849
Mailing address:
  • Phone: 940-683-8361
  • Fax: 940-683-5849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE MENG
Title or Position: BUSINESS MANAGER
Credential:
Phone: 940-683-8361