Basic Information
| Provider Information | |||||||||
| NPI: | 1003102120 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY BRIDGES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | CASA GRANDE INPATIENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1855 W BASELINE RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852029098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808317566 | ||||||||
| FaxNumber: | 4809627671 | ||||||||
| Practice Location | |||||||||
| Address1: | 675 E COTTONWOOD LN STE 140 | ||||||||
| Address2: | |||||||||
| City: | CASA GRANDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851222023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204260088 | ||||||||
| FaxNumber: | 4807752420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2011 | ||||||||
| LastUpdateDate: | 04/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | HOGEBOOM | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4808317566 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY BRIDGES, INC. | ||||||||
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| AuthorizedOfficialCredential: | LISAC | ||||||||
| NPICertificationDate: | 04/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | IFBH9071 | AZ | N | Laboratories | Clinical Medical Laboratory | 343900000X | IFBH9071 | AZ | N | Transportation Services | Non-emergency Medical Transport (VAN) | 261QM0850X | IFBH9071 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 419223 | 05 | AZ | MEDICAID | Z145164 | 01 | AZ | MEDICARE PTAN | OTHER | IFBH9071 | 01 | AZ | ADHS | OTHER |