1558627786 NPI number — COMMUNITY BRIDGES, 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 1558627786 NPI number — COMMUNITY BRIDGES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY BRIDGES, 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:
CENTRAL CITY ADDICTION RECOVERY CENTER
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:
1558627786
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1855 W BASELINE RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85202-9000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-831-7566
Provider Business Mailing Address Fax Number:
480-962-7671

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2770 E VAN BUREN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85008-6088
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-273-9999
Provider Business Practice Location Address Fax Number:
602-225-2409
Provider Enumeration Date:
04/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HOGEBOOM
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
VP/COO
Authorized Official Telephone Number:
480-831-7566

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  03D2036543 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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