Provider Demographics
NPI:1093354037
Name:A BRIDGE BACK, INC.
Entity Type:Organization
Organization Name:A BRIDGE BACK, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LUCIEN
Authorized Official - Middle Name:
Authorized Official - Last Name:IZRAYLOV
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CADC, CODP, QMHP
Authorized Official - Phone:847-877-2440
Mailing Address - Street 1:314 MCHENRY RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-2428
Mailing Address - Country:US
Mailing Address - Phone:844-427-6739
Mailing Address - Fax:
Practice Address - Street 1:314 MCHENRY RD
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-2428
Practice Address - Country:US
Practice Address - Phone:844-427-6739
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-21
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder