Healthcare Provider Details

I. General information

NPI: 1609510809
Provider Name (Legal Business Name): BRIDGEWAY CLINICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2022
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4429 S RIVER BLVD
INDEPENDENCE MO
64055-4659
US

IV. Provider business mailing address

4429 S RIVER BLVD
INDEPENDENCE MO
64055-4659
US

V. Phone/Fax

Practice location:
  • Phone: 816-786-4253
  • Fax:
Mailing address:
  • Phone: 816-786-4253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHEILA HALE
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 816-786-4253