Healthcare Provider Details

I. General information

NPI: 1194561670
Provider Name (Legal Business Name): BRIDGE CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 N 1680 E STE N1
ST GEORGE UT
84790-2596
US

IV. Provider business mailing address

230 N 1680 E STE N1
ST GEORGE UT
84790-2596
US

V. Phone/Fax

Practice location:
  • Phone: 435-313-7237
  • Fax:
Mailing address:
  • Phone: 435-313-7237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TRENT KENWORTHY
Title or Position: OWNER
Credential: NP
Phone: 435-313-7237