Healthcare Provider Details

I. General information

NPI: 1154545879
Provider Name (Legal Business Name): BRIDGEWAY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1089 HAWKINSON AVE
GALESBURG IL
61401-6900
US

IV. Provider business mailing address

1089 HAWKINSON AVE
GALESBURG IL
61401-6900
US

V. Phone/Fax

Practice location:
  • Phone: 309-343-2639
  • Fax: 309-341-4770
Mailing address:
  • Phone: 309-343-2639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number-031
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateIL

VIII. Authorized Official

Name: WILLIAM NELSON
Title or Position: CEO
Credential:
Phone: 309-344-2323