Basic Information
| Provider Information | |||||||||
| NPI: | 1861683542 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRIDGES CLUBHOUSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2105 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | CAYCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290331524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037966179 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2105 COMMERCE DR | ||||||||
| Address2: | |||||||||
| City: | CAYCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290331524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037966179 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2007 | ||||||||
| LastUpdateDate: | 08/07/2007 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
| AuthorizedOfficialMiddleName: | DAWN | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERN | ||||||||
| AuthorizedOfficialTelephone: | 8034631891 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MENTAL HEALTH AMERICA OF SOUTH CAROLINA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | SC | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.