Healthcare Provider Details

I. General information

NPI: 1043925688
Provider Name (Legal Business Name): BRIDGE WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2023
Last Update Date: 01/18/2023
Certification Date: 01/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4645 E CHANDLER BLVD STE 100
PHOENIX AZ
85048-0432
US

IV. Provider business mailing address

4645 E CHANDLER BLVD STE 100
PHOENIX AZ
85048-0432
US

V. Phone/Fax

Practice location:
  • Phone: 724-681-4915
  • Fax:
Mailing address:
  • Phone: 724-681-4915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW MCCUTCHEON
Title or Position: AO/PROVIDER/OWNER
Credential: DC
Phone: 724-681-4915