Provider Demographics
NPI:1598042608
Name:BRIDGE 2 LIFE-ADDISON, LLC
Entity Type:Organization
Organization Name:BRIDGE 2 LIFE-ADDISON, LLC
Other - Org Name:PANDA WAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAZLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-928-0494
Mailing Address - Street 1:PO BOX 2551
Mailing Address - Street 2:
Mailing Address - City:GUASTI
Mailing Address - State:CA
Mailing Address - Zip Code:91743-2551
Mailing Address - Country:US
Mailing Address - Phone:951-928-0494
Mailing Address - Fax:
Practice Address - Street 1:1331 ADDISON WAY
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-3878
Practice Address - Country:US
Practice Address - Phone:951-928-0494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility