Healthcare Provider Details

I. General information

NPI: 1114357647
Provider Name (Legal Business Name): THE BRIDGE TO LIFE RESOURCES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2013
Last Update Date: 11/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 MARKET ST
BROCKTON MA
02301-6736
US

IV. Provider business mailing address

104 MARKET ST
BROCKTON MA
02301-6736
US

V. Phone/Fax

Practice location:
  • Phone: 617-462-6733
  • Fax: 781-963-8992
Mailing address:
  • Phone: 617-462-6733
  • Fax: 781-963-8992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MICHELE PADYMOISE
Title or Position: DIRECTOR
Credential: REGISTERED NURSE
Phone: 617-462-6733