1790269124 NPI number — BRIDGE OF HOPE LIFE TRANSFORMATIONAL SERVICES, LLC

Table of content: (NPI 1790269124)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790269124 NPI number — BRIDGE OF HOPE LIFE TRANSFORMATIONAL SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDGE OF HOPE LIFE TRANSFORMATIONAL SERVICES, LLC
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:
1790269124
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
409 QUEBEC RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLERAIN
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27924-9488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-862-8505
Provider Business Mailing Address Fax Number:
252-862-8512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
114 WEST ST S STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AHOSKIE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27910-3342
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-862-8505
Provider Business Practice Location Address Fax Number:
252-862-8512
Provider Enumeration Date:
09/21/2018

Additional Information

Authorized Official

Authorized Official Last Name:
WALKER
Authorized Official First Name:
LAKEISHA
Authorized Official Middle Name:
YVETTE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
252-862-8505

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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