Healthcare Provider Details

I. General information

NPI: 1710421896
Provider Name (Legal Business Name): BRIDGEPORT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2016
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 CRESTVIEW TER
BRIDGEPORT WV
26330-1010
US

IV. Provider business mailing address

700 CHAPPELL RD
CHARLESTON WV
25304-2704
US

V. Phone/Fax

Practice location:
  • Phone: 304-842-7101
  • Fax: 304-842-7104
Mailing address:
  • Phone: 304-343-1950
  • Fax: 304-343-1947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. LAWRENCE A PACK
Title or Position: MANAGER
Credential:
Phone: 304-343-1950