Healthcare Provider Details

I. General information

NPI: 1235849993
Provider Name (Legal Business Name): COMMUNITY BRIDGES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2022
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2770 E VAN BUREN ST RM E
PHOENIX AZ
85008-6088
US

IV. Provider business mailing address

1855 W BASELINE RD STE 101
MESA AZ
85202-9098
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 TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

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