Provider Demographics
NPI:1114657756
Name:BRIDGE GROUP RESIDENTIAL AND COMMUNITY BASED SERVICES
Entity Type:Organization
Organization Name:BRIDGE GROUP RESIDENTIAL AND COMMUNITY BASED SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:MURRY
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-370-9517
Mailing Address - Street 1:1237 S VAL VISTA DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-6401
Mailing Address - Country:US
Mailing Address - Phone:480-459-9577
Mailing Address - Fax:
Practice Address - Street 1:2859 E VOLTAIRE AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-6017
Practice Address - Country:US
Practice Address - Phone:480-370-9517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility