Basic Information
Provider Information
NPI: 1659662468
EntityType: 2
ReplacementNPI:  
OrganizationName: COMMUNITY BRIDGES, INC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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Mailing Information
Address1: 1811 S ALMA SCHOOL RD
Address2: SUITE 160
City: MESA
State: AZ
PostalCode: 852103001
CountryCode: US
TelephoneNumber: 4808317566
FaxNumber: 4809627671
Practice Location
Address1: 358 E JAVELINA AVE
Address2:  
City: MESA
State: AZ
PostalCode: 852106207
CountryCode: US
TelephoneNumber: 4808317566
FaxNumber: 4809627671
Other Information
ProviderEnumerationDate: 04/27/2011
LastUpdateDate: 04/27/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: HOGEBOOM
AuthorizedOfficialFirstName: JOHN
AuthorizedOfficialMiddleName: F
AuthorizedOfficialTitleorPosition: COO
AuthorizedOfficialTelephone: 4808317566
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: COMMUNITY BRIDGES, INC
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: LISAC
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
251B00000XBH-1453AZY AgenciesCase Management 

No ID Information.


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