Healthcare Provider Details

I. General information

NPI: 1235679523
Provider Name (Legal Business Name): DORIS C. BRIDGES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 03/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3928 ALLEN DR
JACKSON MS
39212-5379
US

IV. Provider business mailing address

3928 ALLEN DR
JACKSON MS
39212-5379
US

V. Phone/Fax

Practice location:
  • Phone: 404-226-4928
  • Fax:
Mailing address:
  • Phone: 404-226-4928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. DORIS CHRISTINA BRIDGES
Title or Position: DIRECTOR/OWNER
Credential:
Phone: 404-226-4928