Basic Information
| Provider Information | |||||||||
| NPI: | 1932609732 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOPEBRIDGE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 DEPAUW BLVD STE 3070 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462686135 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1300 E NEW CIRCLE RD STE 150 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405059001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596851019 | ||||||||
| FaxNumber: | 7654506664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2018 | ||||||||
| LastUpdateDate: | 10/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | GRAFF | ||||||||
| AuthorizedOfficialFirstName: | ANGIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | INSURANCE & CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3173768336 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HOPEBRIDGE, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251P0200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | 225XP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7100556880 | 05 | KY | MEDICAID |