Healthcare Provider Details

I. General information

NPI: 1114840337
Provider Name (Legal Business Name): BRIDGE HEALTH COLLECTIVE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BRANDY LN
ROSEBURG OR
97471-9011
US

IV. Provider business mailing address

133 BRANDY LN
ROSEBURG OR
97471-9011
US

V. Phone/Fax

Practice location:
  • Phone: 541-733-5403
  • Fax:
Mailing address:
  • Phone: 541-733-5403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: HEATHER NICOLE HERNANDEZ
Title or Position: OWNER
Credential: PA-C
Phone: 541-733-5403