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General NPI Number Information
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NPI Number | 1285803148
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Entity Type | Organization
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Legal Business Name | BRIDGEPORT ESSENTIAL PRACTICES, LLC
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Dates
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Enumeration Date | 02/25/2008
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Last Update Date | 02/25/2008
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Provider Practice Location Address
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Address Line | 102 W CATES ST
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City | BRIDGEPORT
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State | TX
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Zip | 76426-2709
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Country | US
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Telephone | 940-683-5183
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Fax |
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Provider Business Mailing Address
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Address Line | 102 W CATES ST
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City | BRIDGEPORT
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State | TX
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Zip | 76426-2709
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Country | US
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Telephone | 940-683-5183
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Fax |
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Authorized Official
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Title or Position | OPERATING MANAGER
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Name | MR. RAYMOND J. WATT
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Credential |
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Telephone | 731-267-2861
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3140N1450X
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Taxonomy Name | Pediatric Skilled Nursing Facility
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License Number | 004054
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License Number State | TX
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