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General NPI Number Information
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NPI Number | 1811449044
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Entity Type | Organization
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Legal Business Name | BRIDGE OF HOPE
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Dates
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Enumeration Date | 11/04/2016
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Last Update Date | 11/04/2016
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Provider Practice Location Address
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Address Line | 400 N WASHINGTON ST
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City | FARMINGTON
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State | MO
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Zip | 63640-1716
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Country | US
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Telephone | 573-438-3733
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Fax | 573-438-0046
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Provider Business Mailing Address
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Address Line | 400 N WASHINGTON
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City | POTOSI
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State | MISSOURI
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Zip | 63664
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Country | UM
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Telephone | 573-438-3733
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | LINDA DECLUE
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Credential |
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Telephone | 573-438-3733
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | 30402638
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License Number State | MO
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