Healthcare Provider Details

I. General information

NPI: 1154798916
Provider Name (Legal Business Name): THE BRIDGE CLINIC OF ROCKOFRD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2015
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 N CHURCH ST
ROCKFORD IL
61101-1006
US

IV. Provider business mailing address

PO BOX 16024
LOVES PARK IL
61132-6024
US

V. Phone/Fax

Practice location:
  • Phone: 815-494-1594
  • Fax:
Mailing address:
  • Phone: 815-494-1594
  • Fax: 866-506-0931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ANNETTE OLIN
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 815-494-1594