Healthcare Provider Details

I. General information

NPI: 1659658516
Provider Name (Legal Business Name): COMMUNITY BRIDGES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2011
Last Update Date: 01/02/2023
Certification Date: 01/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 S OCOTILLO AVE STE 1
BENSON AZ
85602-6403
US

IV. Provider business mailing address

1855 W BASELINE RD SUITE 101
MESA AZ
85202-9000
US

V. Phone/Fax

Practice location:
  • Phone: 480-831-7566
  • Fax:
Mailing address:
  • Phone: 480-831-7566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberOTC6848
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberOTC6848
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberOTC6848
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberOTC6848
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberOTC6848
License Number StateAZ
# 6
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberOTC6848
License Number StateAZ
# 7
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License NumberOTC6848
License Number StateAZ
# 8
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberOTC6848
License Number StateAZ
# 9
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberOTC6848
License Number StateAZ

VIII. Authorized Official

Name: JOHN F HOGEBOOM
Title or Position: PRESIDENT/CEO
Credential: LISAC
Phone: 480-831-7566