Basic Information
Provider Information | |||||||||
NPI: | 1477800308 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY BRIDGES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | YUMA LIGHTHOUSE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1855 W BASELINE RD | ||||||||
Address2: | SUITE 101 | ||||||||
City: | MESA | ||||||||
State: | AZ | ||||||||
PostalCode: | 852029000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4808317566 | ||||||||
FaxNumber: | 4806927671 | ||||||||
Practice Location | |||||||||
Address1: | 3250 B EAST 40TH STREET | ||||||||
Address2: |   | ||||||||
City: | YUMA | ||||||||
State: | AZ | ||||||||
PostalCode: | 85365 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9283414220 | ||||||||
FaxNumber: | 9283444457 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2012 | ||||||||
LastUpdateDate: | 08/09/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOGEBOOM | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP/COO | ||||||||
AuthorizedOfficialTelephone: | 4808317566 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COMMUNITY BRIDGES, INC | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LISAC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 03D2039695 | AZ | Y |   | Laboratories | Clinical Medical Laboratory |   |
No ID Information.