Provider Demographics
NPI:1871923144
Name:525 BRIDGEWATER LLC.
Entity type:Organization
Organization Name:525 BRIDGEWATER LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:P
Authorized Official - Last Name:SHEILDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-377-7773
Mailing Address - Street 1:3233 WARREN CREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141
Mailing Address - Country:US
Mailing Address - Phone:770-377-7773
Mailing Address - Fax:
Practice Address - Street 1:2478 WOOD MEADOWS DRIVE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064
Practice Address - Country:US
Practice Address - Phone:770-377-7773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty