Basic Information
| Provider Information | |||||||||
| NPI: | 1861722175 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY BRIDGES, INC | ||||||||
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| OtherOrganizationName: | LIGHTHOUSE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1855 W. BASELINE RD. | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852029098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808317566 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3250 E 40TH ST | ||||||||
| Address2: | ROOM B | ||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853657994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283414220 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2010 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOGEBOOM | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4808317566 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LISAC | ||||||||
| NPICertificationDate: | 06/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | BH-3480 | AZ | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 291U00000X | BH-3480 | AZ | N | Laboratories | Clinical Medical Laboratory | 324500000X | BH-3480 | AZ | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 343900000X | BH-3480 | AZ | N | Transportation Services | Non-emergency Medical Transport (VAN) | 323P00000X | BH-3480 | AZ | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
ID Information
| ID | Type | State | Issuer | Description | Z148077 | 01 | AZ | MEDICARE PTAN | OTHER | 488183 | 05 | AZ | MEDICAID |