Basic Information
| Provider Information | |||||||||
| NPI: | 1104221209 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRIDGE HOSPICE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 CANAL ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | POOLER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313224094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124174571 | ||||||||
| FaxNumber: | 9124174370 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 CANAL ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | POOLER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124174571 | ||||||||
| FaxNumber: | 9124174370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2014 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | MUSSELMAN | ||||||||
| AuthorizedOfficialFirstName: | AARON | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9124174571 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315D00000X | N | Nursing & Custodial Care Facilities | Hospice, Inpatient | 251G00000X | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 003189404A | 05 | GA | MEDICAID |