Healthcare Provider Details

I. General information

NPI: 1952925984
Provider Name (Legal Business Name): BRIDGE STREET RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 FRANCESTOWN ROAD NH ROUTE 47
BENNINGTON NH
03442
US

IV. Provider business mailing address

608 FRANCESTOWN RD
BENNINGTON NH
03442-4314
US

V. Phone/Fax

Practice location:
  • Phone: 603-255-7070
  • Fax:
Mailing address:
  • Phone: 603-255-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN CHRISTIAN
Title or Position: CEO
Credential: ED.M, MLADC
Phone: 617-620-8528