Healthcare Provider Details

I. General information

NPI: 1124241625
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

301 W CALHOUN ST
MACOMB IL
61455-2154
US

IV. Provider business mailing address

900 S DEER RD
MACOMB IL
61455-2639
US

V. Phone/Fax

Practice location:
  • Phone: 309-836-4172
  • Fax:
Mailing address:
  • Phone: 309-837-4876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number022
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