Basic Information
| Provider Information | |||||||||
| NPI: | 1811580814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRIDGES | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | MYCAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2705 HARTMAN CIR | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760634283 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 11801 SOUTH FWY | ||||||||
| Address2: | |||||||||
| City: | BURLESON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760287021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172939110 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2021 | ||||||||
| LastUpdateDate: | 02/19/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | 895421 | TX | Y | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant |
No ID Information.