Provider Demographics
NPI:1003102120
Name:COMMUNITY BRIDGES, INC.
Entity Type:Organization
Organization Name:COMMUNITY BRIDGES, INC.
Other - Org Name:CASA GRANDE INPATIENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
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 STE 101
Mailing Address - Street 2:
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:480-962-7671
Practice Address - Street 1:675 E COTTONWOOD LN STE 140
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-2023
Practice Address - Country:US
Practice Address - Phone:520-426-0088
Practice Address - Fax:480-775-2420
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY BRIDGES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-27
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 324500000X
AZIFBH9071261QM0850X, 291U00000X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No291U00000XLaboratoriesClinical Medical Laboratory
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZIFBH9071OtherADHS
AZZ145164OtherMEDICARE PTAN
AZ419223Medicaid