Provider Demographics
NPI:1568651602
Name:BRIDGING THE GAP RESIDENTIAL SERVICES, LLC
Entity Type:Organization
Organization Name:BRIDGING THE GAP RESIDENTIAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARSHELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-641-8378
Mailing Address - Street 1:2945 S MIAMI BLVD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-8024
Mailing Address - Country:US
Mailing Address - Phone:919-641-8378
Mailing Address - Fax:919-964-3364
Practice Address - Street 1:2945 S MIAMI BLVD
Practice Address - Street 2:SUITE 114
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-8024
Practice Address - Country:US
Practice Address - Phone:919-641-8378
Practice Address - Fax:919-964-3364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-032-520251C00000X
NCMHL-032-451310400000X
NCMHL-032-419310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418478Medicaid