Provider Demographics
NPI:1619231784
Name:BRIDGEWAY HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:BRIDGEWAY HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHENEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-475-0800
Mailing Address - Street 1:1032 S BRIDGE WAY PL STE 110
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6099
Mailing Address - Country:US
Mailing Address - Phone:208-475-0800
Mailing Address - Fax:
Practice Address - Street 1:1032 S BRIDGE WAY PL STE 110
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6099
Practice Address - Country:US
Practice Address - Phone:208-475-0800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7357261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)