1184041998 NPI number — BRIDGE BACK TO LIFE CENTER, INC.

Table of content: (NPI 1184041998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184041998 NPI number — BRIDGE BACK TO LIFE CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDGE BACK TO LIFE CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184041998
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4271 HEMPSTEAD TPKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BETHPAGE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11714-5708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-520-6600
Provider Business Mailing Address Fax Number:
516-520-6750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3044 CONEY ISLAND AVE
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11235-5660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-265-4200
Provider Business Practice Location Address Fax Number:
718-265-8536
Provider Enumeration Date:
03/19/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BUTCHEN
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
516-520-6600

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  141111254 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163WA0400X , with the licence number: 141111254 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01439087 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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