MEDICARE: BRIDGEBUILDERS

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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	MHL030463	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720142847
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEBUILDERS

Provider Business Mailing Address
First Line	:	PO BOX 3707
Second Line	:
City	:	GASTONIA
State	:	NC
Zip	:	28054-0020
Country	:	US
Telephone Number	:	704-864-4623
Fax Number	:	704-864-3331

Provider Business Practice Location Address
First Line	:	606 HILLSIDE DR
Second Line	:
City	:	KINGS MTN
State	:	NC
Zip	:	28086-3219
Country	:	US
Telephone Number	:	704-864-4623
Fax Number	:	704-864-3331

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. VERNON T GRIER
Credential	:
Telephone Number	:	704-864-4623

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	08/01/2007

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Directions to “BRIDGEBUILDERS ” Practice Location

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