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General NPI Number Information
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NPI Number | 1093354037
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Entity Type | Organization
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Legal Business Name | A BRIDGE BACK, INC.
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Dates
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Enumeration Date | 12/21/2019
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Last Update Date | 11/14/2024
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Provider Practice Location Address
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Address Line | 1655 N ARLINGTON HEIGHTS RD # 305
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City | ARLINGTON HEIGHTS
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State | IL
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Zip | 60004-3982
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Country | US
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Telephone | 844-427-6739
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Fax |
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Provider Business Mailing Address
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Address Line | 314 MCHENRY RD
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City | BUFFALO GROVE
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State | IL
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Zip | 60089-2428
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Country | US
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Telephone | 844-427-6739
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. LUCIEN IZRAYLOV
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Credential | MA, CADC, CODP, QMHP
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Telephone | 847-877-2440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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