Basic Information
| Provider Information | |||||||||
| NPI: | 1134240328 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY BRIDGES, INC. | ||||||||
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| OtherOrganizationName: | EAST VALLEY ADDICTION RECOVERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1855 W. BASELINE RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852029098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809627711 | ||||||||
| FaxNumber: | 4808317563 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 S BELLVIEW | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852042504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809627711 | ||||||||
| FaxNumber: | 4808317563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 04/11/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOGEBOOM | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4808317566 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LISAC | ||||||||
| NPICertificationDate: | 04/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251J00000X | IFBH6337 | AZ | N | Agencies | Nursing Care | 291U00000X | IFBH6337 | AZ | N | Laboratories | Clinical Medical Laboratory | 343900000X | IFBH6337 | AZ | N | Transportation Services | Non-emergency Medical Transport (VAN) | 276400000X | IFBH6337 | AZ | Y | Hospital Units | Rehabilitation, Substance Use Disorder Unit |
ID Information
| ID | Type | State | Issuer | Description | Z145163 | 01 | AZ | MEDICARE PTAN | OTHER | 385867 | 05 | AZ | MEDICAID |