Healthcare Provider Details

I. General information

NPI: 1710295860
Provider Name (Legal Business Name): BRIDGE THE GAP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 07/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9811 W CHARLESTON BLVD STE 2538
LAS VEGAS NV
89117-7528
US

IV. Provider business mailing address

9811 W CHARLESTON BLVD STE. 2-538
LAS VEGAS NV
89117-7528
US

V. Phone/Fax

Practice location:
  • Phone: 702-505-3635
  • Fax:
Mailing address:
  • Phone: 702-202-0789
  • Fax: 702-202-0792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
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 TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: QUINCY SANDERS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 702-505-3635