Provider Demographics
NPI:1982070314
Name:BRIDGE HAVEN MEMORY CARE, LLC
Entity type:Organization
Organization Name:BRIDGE HAVEN MEMORY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-371-1106
Mailing Address - Street 1:1126 HILLTOP DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-4530
Mailing Address - Country:US
Mailing Address - Phone:785-371-1106
Mailing Address - Fax:
Practice Address - Street 1:2147 QUAIL CREEK DR
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66047-2142
Practice Address - Country:US
Practice Address - Phone:785-371-1106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSB023017311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)