Healthcare Provider Details

I. General information

NPI: 1568651602
Provider Name (Legal Business Name): BRIDGING THE GAP RESIDENTIAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2945 S MIAMI BLVD SUITE 114
DURHAM NC
27703-8024
US

IV. Provider business mailing address

2945 S MIAMI BLVD SUITE 114
DURHAM NC
27703-8024
US

V. Phone/Fax

Practice location:
  • Phone: 919-641-8378
  • Fax: 919-964-3364
Mailing address:
  • Phone: 919-641-8378
  • Fax: 919-964-3364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License NumberMHL-032-520
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberMHL-032-451
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberMHL-032-419
License Number StateNC

VIII. Authorized Official

Name: MARSHELIA BENTON
Title or Position: OWNER
Credential:
Phone: 919-641-8378