Healthcare Provider Details

I. General information

NPI: 1003353244
Provider Name (Legal Business Name): COMMUNITY BRIDGES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2017
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 O'HARA AVENUE
BISBEE AZ
85603
US

IV. Provider business mailing address

1855 W BASELINE RD STE 101
MESA AZ
85202-9098
US

V. Phone/Fax

Practice location:
  • Phone: 520-432-8068
  • Fax: 520-432-6962
Mailing address:
  • Phone: 480-831-7566
  • Fax: 480-831-7576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberBH5106
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberBH5106
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

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