Provider Demographics
NPI:1245557404
Name:BRIDGEWAY PSYCHIATRIC CENTER, INC.
Entity Type:Organization
Organization Name:BRIDGEWAY PSYCHIATRIC CENTER, INC.
Other - Org Name:BRIDGEWAY PSYCHIATRIC CENTER PRACTICE MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:CULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-788-3330
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:LA
Mailing Address - Zip Code:70527-0428
Mailing Address - Country:US
Mailing Address - Phone:337-785-8003
Mailing Address - Fax:337-785-8045
Practice Address - Street 1:3451 5TH AVE
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70607-2127
Practice Address - Country:US
Practice Address - Phone:337-562-0211
Practice Address - Fax:337-562-0212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty