Provider Demographics
NPI:1114357647
Name:THE BRIDGE TO LIFE RESOURCES INC
Entity Type:Organization
Organization Name:THE BRIDGE TO LIFE RESOURCES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:PADYMOISE
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:617-462-6733
Mailing Address - Street 1:104 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-6736
Mailing Address - Country:US
Mailing Address - Phone:617-462-6733
Mailing Address - Fax:781-963-8992
Practice Address - Street 1:104 MARKET ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-6736
Practice Address - Country:US
Practice Address - Phone:617-462-6733
Practice Address - Fax:781-963-8992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty
No385H00000XRespite Care FacilityRespite CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1041Medicaid
MA4220Medicare PIN
MA1041Medicaid
MA10421130Medicare Oscar/Certification
MA4221Medicare UPIN