Healthcare Provider Details

I. General information

NPI: 1780104950
Provider Name (Legal Business Name): BRIDGE OF LOVE AND PEACE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 MOUNTAINVIEW AVE
ORANGEBURG NY
10962-1208
US

IV. Provider business mailing address

13 MOUNTAINVIEW AVE
ORANGEBURG NY
10962-1208
US

V. Phone/Fax

Practice location:
  • Phone: 646-844-5070
  • Fax:
Mailing address:
  • Phone: 646-844-5070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: JOO SONG LEE
Title or Position: DIRECTOR
Credential:
Phone: 718-813-6848