=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205443371
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGEWATER HEALTH SUPPLIES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2020
-----------------------------------------------------
Last Update Date | 02/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2605 TEXAS BLVD STE 102
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-4161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-255-0097
-----------------------------------------------------
Fax | 516-908-4383
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2605 TEXAS BLVD STE 102
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75503-4161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-255-0097
-----------------------------------------------------
Fax | 516-908-4383
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | MR. STEVEN FRANEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 631-579-5308
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------