Healthcare Provider Details

I. General information

NPI: 1619231784
Provider Name (Legal Business Name): BRIDGEWAY HEALTH SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2012
Last Update Date: 07/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 S BRIDGE WAY PL STE 110
EAGLE ID
83616-6099
US

IV. Provider business mailing address

1032 S BRIDGE WAY PL STE 110
EAGLE ID
83616-6099
US

V. Phone/Fax

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

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: MS. STEPHANIE CHENEY
Title or Position: BUSINESS MANAGER
Credential:
Phone: 208-475-0800