Healthcare Provider Details

I. General information

NPI: 1174914048
Provider Name (Legal Business Name): BRIDGE TO SHORE RECOVERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2015
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 US 1 S
ST AUGUSTINE FL
32086-7089
US

IV. Provider business mailing address

3930 US 1 S
ST AUGUSTINE FL
32086-7089
US

V. Phone/Fax

Practice location:
  • Phone: 904-540-4232
  • Fax:
Mailing address:
  • Phone: 904-540-4232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number5501
License Number StateFL

VIII. Authorized Official

Name: PHILLIP D SNYDER
Title or Position: ADMISSIONS SUPERVISOR
Credential:
Phone: 904-217-0480