Basic Information
Provider Information | |||||||||
NPI: | 1356461727 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY BRIDGES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ARIZONA BRIDGE TO RECOVERY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1855 W. BASELINE RD. | ||||||||
Address2: | SUITE 101 | ||||||||
City: | MESA | ||||||||
State: | AZ | ||||||||
PostalCode: | 852029098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4808317566 | ||||||||
FaxNumber: | 4808317563 | ||||||||
Practice Location | |||||||||
Address1: | 554 S BELLVIEW RM B | ||||||||
Address2: |   | ||||||||
City: | MESA | ||||||||
State: | AZ | ||||||||
PostalCode: | 852042504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4806491141 | ||||||||
FaxNumber: | 4808317563 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/30/2007 | ||||||||
LastUpdateDate: | 06/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOGEBOOM | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
AuthorizedOfficialTelephone: | 4808317566 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LISAC | ||||||||
NPICertificationDate: | 06/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251J00000X | IFBH6334 | AZ | N |   | Agencies | Nursing Care |   | 291U00000X | IFBH6334 | AZ | N |   | Laboratories | Clinical Medical Laboratory |   | 343900000X | IFBH6334 | AZ | N |   | Transportation Services | Non-emergency Medical Transport (VAN) |   | 276400000X | IFBH6334 | AZ | Y |   | Hospital Units | Rehabilitation, Substance Use Disorder Unit |   |
ID Information
ID | Type | State | Issuer | Description | 419683 | 05 | AZ |   | MEDICAID | Z145163 | 01 | AZ | MEDICARE PTAN | OTHER |