1265004576 NPI number — BRIDGE TO SHORE RECOVERY, LLC

Table of content: (NPI 1265004576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265004576 NPI number — BRIDGE TO SHORE RECOVERY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDGE TO SHORE RECOVERY, 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:
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:
1265004576
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3930 US 1 S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT AUGUSTINE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32086-7089
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-217-0480
Provider Business Mailing Address Fax Number:
904-217-3081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 DAVIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT AUGUSTINE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32084-0476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
42-170-4809
Provider Business Practice Location Address Fax Number:
904-217-3081
Provider Enumeration Date:
07/15/2021

Additional Information

Authorized Official

Authorized Official Last Name:
SNYDER
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
D
Authorized Official Title or Position:
ADMISSIONS SUPERVISOR
Authorized Official Telephone Number:
904-217-0480

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ME38055 . This is a "MD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: MH17663 . This is a "LMHC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: SW16603 . This is a "LCSW" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: APRN2520572 . This is a "APRN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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