1205092608 NPI number — COMMUNITY BRIDGES, INC.

Table of content: (NPI 1205092608)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205092608 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:
Provider Other Organization Name Type Code:
6
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:
1205092608
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2023
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 STE 101
Provider Second Line Business Mailing Address:
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:
803 W MAIN ST STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PAYSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85541-4993
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-468-0022
Provider Business Practice Location Address Fax Number:
928-468-0044
Provider Enumeration Date:
08/05/2008

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: 291U00000X , with the licence number:  252714 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 323P00000X , with the licence number: 252714 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 324500000X , with the licence number: 252714 , 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: 252714 , 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: 252714 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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