Provider Demographics
NPI:1083986681
Name:BRIDGEMILL FAMILY HEALTHCARE, LLC
Entity Type:Organization
Organization Name:BRIDGEMILL FAMILY HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:MR
Authorized Official - First Name:OTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:770-866-5488
Mailing Address - Street 1:3760 SIXES RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-8192
Mailing Address - Country:US
Mailing Address - Phone:770-704-4580
Mailing Address - Fax:
Practice Address - Street 1:3760 SIXES RD
Practice Address - Street 2:SUITE 120
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-8192
Practice Address - Country:US
Practice Address - Phone:770-704-4580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROGRESSIVE COMMUNITY HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA111N00000X, 207Q00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty