=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043612344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGES COMMUNITY SUPPORT SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2014
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5222 ANDRUS AVE STE C
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32810-5456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-745-5022
-----------------------------------------------------
Fax | 407-601-4302
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5222 ANDRUS AVE STE C
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32810-5456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-745-5022
-----------------------------------------------------
Fax | 407-601-4302
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | OMUSI RANGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-745-5022
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 0106165
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------