Basic Information
| Provider Information | |||||||||
| NPI: | 1245610567 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY BRIDGES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALBERT LONG RESIDENTIAL PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1855 W BASELINE RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852029000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808317566 | ||||||||
| FaxNumber: | 4809627671 | ||||||||
| Practice Location | |||||||||
| Address1: | 993 HERMOSA DR | ||||||||
| Address2: | AREA B | ||||||||
| City: | HOLBROOK | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 860252036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285241151 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2015 | ||||||||
| LastUpdateDate: | 06/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | HOGEBOOM | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4808317566 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | BH4570 | AZ | N | Residential Treatment Facilities | Psychiatric Residential Treatment Facility | 324500000X | BH4570 | AZ | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.