MEDICARE: BRIDGE TO LIFE MINISTRIES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1306400189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGE TO LIFE MINISTRIES

Provider Business Mailing Address
First Line	:	17194 VAN WAGONER RD
Second Line	:
City	:	SPRING LAKE
State	:	MI
Zip	:	49456-9793
Country	:	US
Telephone Number	:	616-846-1051
Fax Number	:

Provider Business Practice Location Address
First Line	:	17194 VAN WAGONER RD
Second Line	:
City	:	SPRING LAKE
State	:	MI
Zip	:	49456-9793
Country	:	US
Telephone Number	:	616-846-1051
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DON SMITH
Credential	:
Telephone Number	:	616-846-1051

Provider Enumeration Date	:	04/26/2019
Last Update Date	:	04/26/2019

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Directions to “BRIDGE TO LIFE MINISTRIES ” Practice Location

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