Provider Demographics
NPI:1639294879
Name:BRIDGEWAY REHABILITATION SERVICES
Entity Type:Organization
Organization Name:BRIDGEWAY REHABILITATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CORY
Authorized Official - Middle Name:
Authorized Official - Last Name:STORCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-355-7886
Mailing Address - Street 1:615 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-3409
Mailing Address - Country:US
Mailing Address - Phone:908-355-7886
Mailing Address - Fax:908-355-6668
Practice Address - Street 1:615 N BROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-3409
Practice Address - Country:US
Practice Address - Phone:908-355-7886
Practice Address - Fax:908-355-6668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ204011310251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherTAX ID