Healthcare Provider Details

I. General information

NPI: 1609099118
Provider Name (Legal Business Name): BRIDGEWAY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 N GROVE ST
KEWANEE IL
61443-2078
US

IV. Provider business mailing address

2323 WINDISH DR
GALESBURG IL
61401-9780
US

V. Phone/Fax

Practice location:
  • Phone: 309-852-6526
  • Fax:
Mailing address:
  • Phone: 309-344-4208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number032
License Number StateIL

VIII. Authorized Official

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