MEDICARE: BRIDGE HOSPICE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251G00000X	Community Based Hospice Care Agency

General Provider Information

NPI Number	:	1811576614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGE HOSPICE LLC

Provider Business Mailing Address
First Line	:	1695 MESQUITE AVE STE 202
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5687
Country	:	US
Telephone Number	:	928-493-4410
Fax Number	:	928-302-1907

Provider Business Practice Location Address
First Line	:	1695 MESQUITE AVE STE 202
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5687
Country	:	US
Telephone Number	:	928-493-4410
Fax Number	:	928-302-1907

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MARK H POWELL
Credential	:	MSN RN
Telephone Number	:	928-493-4410

Provider Enumeration Date	:	04/07/2021
Last Update Date	:	04/07/2021

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