Provider Demographics
NPI:1497344147
Name:BRIDGEWAY RESIDENTIAL CARE FACILITY, LLC
Entity Type:Organization
Organization Name:BRIDGEWAY RESIDENTIAL CARE FACILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDROFF
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:573-489-0246
Mailing Address - Street 1:828 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-1877
Mailing Address - Country:US
Mailing Address - Phone:573-642-7770
Mailing Address - Fax:
Practice Address - Street 1:828 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-1877
Practice Address - Country:US
Practice Address - Phone:573-642-7770
Practice Address - Fax:573-642-7790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-15
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities