Healthcare Provider Details

I. General information

NPI: 1285985929
Provider Name (Legal Business Name): BRIDGEWOOD LAKE JACKSON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2012
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E PARKWOOD AVE STE 100
FRIENDSWOOD TX
77546-5152
US

IV. Provider business mailing address

130 LAKE RD
LAKE JACKSON TX
77566-3258
US

V. Phone/Fax

Practice location:
  • Phone: 281-996-0101
  • Fax: 281-996-1141
Mailing address:
  • Phone: 979-285-0300
  • Fax: 979-285-0338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES D. GRAY
Title or Position: MANAGER
Credential:
Phone: 713-623-6767