Provider Demographics
NPI:1043081045
Name:BRIDGE OF LOVE LLC
Entity Type:Organization
Organization Name:BRIDGE OF LOVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SEERA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-224-3223
Mailing Address - Street 1:8929 W VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-3628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8929 W VERNON AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3628
Practice Address - Country:US
Practice Address - Phone:928-224-3223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care