MEDICARE: COMMUNITY BRIDGES, INC

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	291U00000X	Clinical Medical Laboratory	03D2036539	AZ

General Provider Information

NPI Number	:	1851667083
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY BRIDGES, INC

Provider Business Mailing Address
First Line	:	1855 W BASELINE RD
Second Line	:	SUITE 101
City	:	MESA
State	:	AZ
Zip	:	85202-9000
Country	:	US
Telephone Number	:	480-831-7566
Fax Number	:	480-962-7671

Provider Business Practice Location Address
First Line	:	8825 N 23RD AVE
Second Line	:	SUITE 100
City	:	PHOENIX
State	:	AZ
Zip	:	85021-4147
Country	:	US
Telephone Number	:	602-861-2255
Fax Number	:	602-861-2288

Authorized Official
Title or Position	:	VP/COO
Name	:	JOHN HOGEBOOM
Credential	:	LISAC
Telephone Number	:	480-831-7566

Provider Enumeration Date	:	04/02/2012
Last Update Date	:	04/02/2012

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Directions to “COMMUNITY BRIDGES, INC ” Practice Location

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