Basic Information
| Provider Information | |||||||||
| NPI: | 1588920714 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY BRIDGES, INC | ||||||||
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| OtherOrganizationName: | BENSON OUTPT SERVICE CENTER | ||||||||
| 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: | 732 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | BENSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856026435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205864691 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2012 | ||||||||
| LastUpdateDate: | 04/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | HOGEBOOM | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP/COO | ||||||||
| 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 | 03D2036401 | AZ | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.