Provider Demographics
NPI:1861383184
Name:BRIDGE OF LIFE SUPPORT SERVICES
Entity type:Organization
Organization Name:BRIDGE OF LIFE SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-813-3696
Mailing Address - Street 1:2201 MOTLEY WAY
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4919
Mailing Address - Country:US
Mailing Address - Phone:407-813-3696
Mailing Address - Fax:407-813-3696
Practice Address - Street 1:2201 MOTLEY WAY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4919
Practice Address - Country:US
Practice Address - Phone:407-813-3696
Practice Address - Fax:407-813-3696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities