Provider Demographics
NPI:1093593386
Name:BRIDGE OF CARE GROUP HOME LLC
Entity Type:Organization
Organization Name:BRIDGE OF CARE GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ASHLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAIRSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-305-6637
Mailing Address - Street 1:5108 MALIBU CT
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45426-2353
Mailing Address - Country:US
Mailing Address - Phone:937-305-6637
Mailing Address - Fax:
Practice Address - Street 1:1312 STUBEN DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-8252
Practice Address - Country:US
Practice Address - Phone:937-305-6637
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1639862626Medicaid