Provider Demographics
NPI:1174856645
Name:LIFEBRIDGE INVESTMENTS
Entity Type:Organization
Organization Name:LIFEBRIDGE INVESTMENTS
Other - Org Name:LIFEBRIDGE COMMUNITY PRACTICES DBA CLINICAL ASSOCIATES SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:BEASLEY
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-494-1212
Mailing Address - Street 1:2401 W BELVEDERE AVE
Mailing Address - Street 2:CREDENTIALING
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5216
Mailing Address - Country:US
Mailing Address - Phone:410-601-5523
Mailing Address - Fax:
Practice Address - Street 1:750 MAIN ST
Practice Address - Street 2:SUITE 301A
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-2515
Practice Address - Country:US
Practice Address - Phone:410-526-3060
Practice Address - Fax:410-526-3091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-15
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1490152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD169004Medicare PIN