1255467031 NPI number — COMMUNITY BRIDGES WEST, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255467031 NPI number — COMMUNITY BRIDGES WEST, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY BRIDGES WEST, 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:
JERICHO HOME
Provider Other Organization Name Type Code:
3
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:
1255467031
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 715
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUSTON
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
71273-0715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
318-255-9137
Provider Business Mailing Address Fax Number:
318-255-8233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2515 BROWNLEE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSSIER CITY
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
71111-2011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
318-255-9137
Provider Business Practice Location Address Fax Number:
318-255-8233
Provider Enumeration Date:
02/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
REYNOLDS
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
318-255-9137

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , with the licence number:  896 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1718441 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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