Basic Information
| Provider Information | |||||||||
| NPI: | 1548416514 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY BRIDGES, INC | ||||||||
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| OtherOrganizationName: | PAYSON OUTPATIENT SERVICES 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: | 4808317566 | ||||||||
| FaxNumber: | 4809627671 | ||||||||
| Practice Location | |||||||||
| Address1: | 803 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PAYSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855414993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284680022 | ||||||||
| FaxNumber: | 9284680044 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2008 | ||||||||
| LastUpdateDate: | 02/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | HOGEBOOM | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | VP/COO | ||||||||
| AuthorizedOfficialTelephone: | 4808317566 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY BRIDGES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LISAC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | OTC6017 | AZ | N | Agencies | Community/Behavioral Health | 251J00000X | OTC6017 | AZ | N | Agencies | Nursing Care | 261QM0850X | OTC6017 | AZ | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QH0100X | OTC6017 | AZ | N | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 261QR0405X | OTC6017 | AZ | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QR1300X | OTC6017 | AZ | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 291U00000X | OTC6017 | AZ | N | Laboratories | Clinical Medical Laboratory | 343900000X | OTC6017 | AZ | N | Transportation Services | Non-emergency Medical Transport (VAN) | 251B00000X | OTC6017 | AZ | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 357379 | 05 | AZ | MEDICAID | Z145164 | 01 | AZ | MEDICARE PTAN | OTHER |