Healthcare Provider Details

I. General information

NPI: 1588920714
Provider Name (Legal Business Name): COMMUNITY BRIDGES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2012
Last Update Date: 04/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 W 4TH ST
BENSON AZ
85602-6435
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 520-586-4691
  • Fax:
Mailing address:
  • Phone: 480-831-7566
  • Fax: 480-962-7671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number03D2036401
License Number StateAZ

VIII. Authorized Official

Name: JOHN HOGEBOOM
Title or Position: VP/COO
Credential: LISAC
Phone: 480-831-7566