Basic Information
| Provider Information | |||||||||
| NPI: | 1790419000 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY BRIDGES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1855 W BASELINE RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852029098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808317566 | ||||||||
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| Practice Location | |||||||||
| Address1: | 170 NORTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | FREDONIA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808317566 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2022 | ||||||||
| LastUpdateDate: | 07/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | HOGEBOOM | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4808317566 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | N | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 261QR1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | OTC11792 | 01 | AZ | ADHS | OTHER |