Healthcare Provider Details

I. General information

NPI: 1497344147
Provider Name (Legal Business Name): BRIDGEWAY RESIDENTIAL CARE FACILITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2021
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 JEFFERSON ST
FULTON MO
65251-1877
US

IV. Provider business mailing address

828 JEFFERSON ST
FULTON MO
65251-1877
US

V. Phone/Fax

Practice location:
  • Phone: 573-642-7770
  • Fax: 573-642-7790
Mailing address:
  • Phone: 573-642-7770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. SUE RUDROFF
Title or Position: RN/OWNER
Credential: RN
Phone: 573-489-0246