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General NPI Number Information
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NPI Number | 1861383184
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Entity Type | Organization
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Legal Business Name | BRIDGE OF LIFE SUPPORT SERVICES
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Dates
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Enumeration Date | 07/14/2025
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Last Update Date | 07/14/2025
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Provider Practice Location Address
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Address Line | 2201 MOTLEY WAY
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City | TAVARES
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State | FL
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Zip | 32778-4919
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Country | US
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Telephone | 407-813-3696
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Fax | 407-813-3696
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Provider Business Mailing Address
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Address Line | 2201 MOTLEY WAY
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City | TAVARES
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State | FL
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Zip | 32778-4919
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Country | US
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Telephone | 407-813-3696
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Fax | 407-813-3696
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | TAMARA SHADE
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Credential |
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Telephone | 407-813-3696
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 |
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License Number State |
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