Healthcare Provider Details

I. General information

NPI: 1407024284
Provider Name (Legal Business Name): BRIDGEWAY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 HAWTHORNE CT
GALESBURG IL
61401-1200
US

IV. Provider business mailing address

2323 WINDISH DR
GALESBURG IL
61401-9780
US

V. Phone/Fax

Practice location:
  • Phone: 309-344-2323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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