MEDICARE: BRIDGEPORT SENIOR LIVING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	AL2280	FL

General Provider Information

NPI Number	:	1083957039
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEPORT SENIOR LIVING LLC

Provider Business Mailing Address
First Line	:	13546 DARCHANCE RD
Second Line	:
City	:	WINDERMERE
State	:	FL
Zip	:	34786-6305
Country	:	US
Telephone Number	:	407-760-3648
Fax Number	:	877-784-0844

Provider Business Practice Location Address
First Line	:	8341 LAKE CROWELL CIR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32836-5931
Country	:	US
Telephone Number	:	407-730-2582
Fax Number	:	407-730-2642

Authorized Official
Title or Position	:	OWNER
Name	:	MR. KEVIN GALBASINI
Credential	:
Telephone Number	:	407-760-3649

Provider Enumeration Date	:	03/28/2013
Last Update Date	:	03/28/2013

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