Healthcare Provider Details

I. General information

NPI: 1760618458
Provider Name (Legal Business Name): BRIDGE TO HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2009
Last Update Date: 07/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2149 VELP AVE SUITE 205
GREEN BAY WI
54303-5424
US

IV. Provider business mailing address

2149 VELP AVE SUITE 205
GREEN BAY WI
54303-5424
US

V. Phone/Fax

Practice location:
  • Phone: 920-434-8500
  • Fax: 920-468-9791
Mailing address:
  • Phone: 920-434-8500
  • Fax: 920-468-9791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License Number79614
License Number StateWI

VIII. Authorized Official

Name: MS. BONNIE LEE GROESSL
Title or Position: OWNER/NURSE PRACTITIONER
Credential: MSN
Phone: 920-434-8500