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General NPI Number Information
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NPI Number | 1578824538
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Entity Type | Organization
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Legal Business Name | BRIDGEWAY RESIDENTIAL SERVICES
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Dates
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Enumeration Date | 06/06/2012
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Last Update Date | 06/06/2012
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Provider Practice Location Address
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Address Line | 5118 BRIDGESIDE DR
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23234-2860
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Country | US
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Telephone | 804-301-2984
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Fax | 804-279-0736
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Provider Business Mailing Address
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Address Line | 5118 BRIDGESIDE DR
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City | NORTH CHESTERFIELD
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State | VA
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Zip | 23234-2860
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Country | US
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Telephone | 804-301-2984
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Fax | 804-279-0736
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | MS. DENINEZ MOSS
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Credential |
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Telephone | 804-301-2984
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 1366
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 1366
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License Number State | VA
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