1639119068 NPI number — COMMUNITY BRIDGES, INC.

Table of content: (NPI 1639119068)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639119068 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:
EAST VALLEY ADDICTION RECOVERY CENTER (EVARC)
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:
1639119068
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2023
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:
85202-9098
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:
560 S BELLVIEW RM A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85204-2504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-962-7711
Provider Business Practice Location Address Fax Number:
480-844-8449
Provider Enumeration Date:
06/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOGEBOOM
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
480-831-7566

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  OTC6336 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251J00000X , with the licence number: OTC6336 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: OTC6336 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QH0100X , with the licence number: OTC6336 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X , with the licence number: OTC6336 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0405X , with the licence number: OTC6336 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X , with the licence number: OTC6336 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 343900000X , with the licence number: OTC6336 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: Z145163 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 453702 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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