Healthcare Provider Details

I. General information

NPI: 1972296382
Provider Name (Legal Business Name): BRIDGEWELL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 W BOUGHTON RD STE A
BOLINGBROOK IL
60440-1998
US

IV. Provider business mailing address

402 W BOUGHTON RD STE A
BOLINGBROOK IL
60440-1998
US

V. Phone/Fax

Practice location:
  • Phone: 312-451-6148
  • Fax:
Mailing address:
  • Phone: 312-451-6148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ISOKEN OGBOMO
Title or Position: NURSE PRACTITIONER
Credential: FNP
Phone: 312-451-6418