Provider Demographics
NPI:1861722175
Name:COMMUNITY BRIDGES, INC
Entity type:Organization
Organization Name:COMMUNITY BRIDGES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:HOGEBOOM
Authorized Official - Suffix:
Authorized Official - Credentials:LISAC
Authorized Official - Phone:480-831-7566
Mailing Address - Street 1:1855 W. BASELINE RD.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-9098
Mailing Address - Country:US
Mailing Address - Phone:480-831-7566
Mailing Address - Fax:
Practice Address - Street 1:3250 E 40TH ST
Practice Address - Street 2:ROOM B
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85365-7994
Practice Address - Country:US
Practice Address - Phone:928-341-4220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-08
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH-3480261QR1300X, 291U00000X, 323P00000X, 324500000X, 343900000X
320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No291U00000XLaboratoriesClinical Medical Laboratory
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ488183Medicaid
AZZ148077OtherMEDICARE PTAN