Healthcare Provider Details

I. General information

NPI: 1265703953
Provider Name (Legal Business Name): BRIDGEWAY HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2012
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 S. BRIDGEWAY PL, STE 110
EAGLE ID
83616
US

IV. Provider business mailing address

1032 S. BRIDGEWAY PL, STE 110
EAGLE ID
83616
US

V. Phone/Fax

Practice location:
  • Phone: 208-475-0800
  • Fax: 208-639-0901
Mailing address:
  • Phone: 208-475-0800
  • Fax: 208-639-0901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberM7357
License Number StateID

VIII. Authorized Official

Name: DR. GRANT BELNAP
Title or Position: OWNER
Credential: MD
Phone: 208-246-0123