Healthcare Provider Details

I. General information

NPI: 1477418853
Provider Name (Legal Business Name): CARE BRIDGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

658 SW CEDAR ST
MILL CITY OR
97360
US

IV. Provider business mailing address

658 SW CEDAR ST
MILL CITY OR
97360
US

V. Phone/Fax

Practice location:
  • Phone: 781-309-8976
  • Fax:
Mailing address:
  • Phone: 781-309-8976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: WILSON KISAMBIRA
Title or Position: DIRECTOR
Credential:
Phone: 781-309-8976