MEDICARE: THE BRIDGE AT FAIR PARK, 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	261QA0600X	Adult Day Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	102501	OTHER	TX	ADULT DAY CARE FACILITY #
2	119241	OTHER	TX	ADULT DAY CARE LICENSE #

General Provider Information

NPI Number	:	1801923198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BRIDGE AT FAIR PARK, LLC

Provider Business Mailing Address
First Line	:	2535 MARTIN LUTHER KING JR BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75215-2306
Country	:	US
Telephone Number	:	214-565-7823
Fax Number	:	214-565-0246

Provider Business Practice Location Address
First Line	:	2535 MARTIN LUTHER KING JR BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75215-2306
Country	:	US
Telephone Number	:	214-565-7823
Fax Number	:	214-565-0246

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	PAULA WATKINS
Credential	:
Telephone Number	:	214-565-7823

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	07/16/2024

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Directions to “THE BRIDGE AT FAIR PARK, LLC ” Practice Location

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