Provider Demographics
NPI:1093930497
Name:BRIDGEWAY, INC.
Entity Type:Organization
Organization Name:BRIDGEWAY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAYNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-762-1462
Mailing Address - Street 1:620 W. GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601
Mailing Address - Country:US
Mailing Address - Phone:580-762-1462
Mailing Address - Fax:580-765-7299
Practice Address - Street 1:620 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-5123
Practice Address - Country:US
Practice Address - Phone:580-762-1462
Practice Address - Fax:580-765-7299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility