Provider Demographics
NPI:1073649463
Name:COMMUNITY BRIDGES SOUTH, INC.
Entity Type:Organization
Organization Name:COMMUNITY BRIDGES SOUTH, INC.
Other - Org Name:CAMPBELL STREET HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:L
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-255-1937
Mailing Address - Street 1:PO BOX 715
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71273-0715
Mailing Address - Country:US
Mailing Address - Phone:318-255-1937
Mailing Address - Fax:318-255-8233
Practice Address - Street 1:1406 CAMPBELL STREET
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270
Practice Address - Country:US
Practice Address - Phone:318-255-1937
Practice Address - Fax:318-255-8233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1035315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1710431Medicaid
LA19G253Medicare UPIN