MEDICARE: BRIDGEWAY RESIDENTIAL SERVICES

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	1366	VA
2	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	1366	VA

General Provider Information

NPI Number	:	1578824538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEWAY RESIDENTIAL SERVICES

Provider Business Mailing Address
First Line	:	5118 BRIDGESIDE DR
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23234-2860
Country	:	US
Telephone Number	:	804-301-2984
Fax Number	:	804-279-0736

Provider Business Practice Location Address
First Line	:	5118 BRIDGESIDE DR
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23234-2860
Country	:	US
Telephone Number	:	804-301-2984
Fax Number	:	804-279-0736

Authorized Official
Title or Position	:	PROGRAM DIRECTOR
Name	:	MS. DENINEZ MOSS
Credential	:
Telephone Number	:	804-301-2984

Provider Enumeration Date	:	06/06/2012
Last Update Date	:	06/06/2012

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Directions to “BRIDGEWAY RESIDENTIAL SERVICES ” Practice Location

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