Healthcare Provider Details

I. General information

NPI: 1972967842
Provider Name (Legal Business Name): BRIDGEWAY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 WINDISH DR
GALESBURG IL
61401-9780
US

IV. Provider business mailing address

2323 WINDISH DR
GALESBURG IL
61401-9780
US

V. Phone/Fax

Practice location:
  • Phone: 309-344-2323
  • Fax: 309-344-4281
Mailing address:
  • Phone: 309-344-2323
  • Fax: 309-344-4281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM NELSON
Title or Position: CEO
Credential:
Phone: 309-344-4337