1710625116 NPI number — BRIDGEWAY LIFE DEVELOPMENT FOUNDATION

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 1710625116 NPI number — BRIDGEWAY LIFE DEVELOPMENT FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDGEWAY LIFE DEVELOPMENT FOUNDATION
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:
1710625116
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
312 SABINE RIVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENN HEIGHTS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75154-5582
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-945-0232
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 W MAIN ST STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OVILLA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75154-1618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-945-0232
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/25/2022

Additional Information

Authorized Official

Authorized Official Last Name:
LONG-WASHINGTON
Authorized Official First Name:
ASHLEE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
214-945-0232

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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