Basic Information
| Provider Information | |||||||||
| NPI: | 1366722555 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY BRIDGES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WEST VALLEY TRANSITION POINT | ||||||||
| 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: | 4808317566 | ||||||||
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| Practice Location | |||||||||
| Address1: | 824 N 99TH AVE | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | AVONDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853235315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808317566 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2011 | ||||||||
| LastUpdateDate: | 09/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | HOGEBOOM | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | DEPUTY CEO | ||||||||
| AuthorizedOfficialTelephone: | 4808317566 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY BRIDGES, INC. | ||||||||
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| AuthorizedOfficialCredential: | LISAC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 343900000X | N | Transportation Services | Non-emergency Medical Transport (VAN) | 261QH0100X | N | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | Z145163 | 01 | AZ | MEDICARE PTAN | OTHER |