Healthcare Provider Details

I. General information

NPI: 1194642082
Provider Name (Legal Business Name): JUSTIN BRIDGE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

749 PANTEGO BLVD SE
BOLIVIA NC
28422-8397
US

IV. Provider business mailing address

749 PANTEGO BLVD SE
BOLIVIA NC
28422-8397
US

V. Phone/Fax

Practice location:
  • Phone: 910-409-3608
  • Fax:
Mailing address:
  • Phone: 910-409-3608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP060688
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: