Provider Demographics
NPI:1659647766
Name:BRIDGE OF EMPOWERMENT,LLC
Entity Type:Organization
Organization Name:BRIDGE OF EMPOWERMENT,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-318-3946
Mailing Address - Street 1:675 NC HIGHWAY 71 N
Mailing Address - Street 2:
Mailing Address - City:MAXTON
Mailing Address - State:NC
Mailing Address - Zip Code:28364-8741
Mailing Address - Country:US
Mailing Address - Phone:910-318-3946
Mailing Address - Fax:
Practice Address - Street 1:651 EAST WILMINGTON STREET
Practice Address - Street 2:
Practice Address - City:MAXTON
Practice Address - State:NC
Practice Address - Zip Code:28364
Practice Address - Country:US
Practice Address - Phone:910-318-3946
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-23
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health