Provider Demographics
NPI:1710295860
Name:BRIDGE THE GAP LLC
Entity Type:Organization
Organization Name:BRIDGE THE GAP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:QUINCY
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-505-3635
Mailing Address - Street 1:9811 W CHARLESTON BLVD
Mailing Address - Street 2:STE. 2-538
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-7528
Mailing Address - Country:US
Mailing Address - Phone:702-202-0789
Mailing Address - Fax:702-202-0792
Practice Address - Street 1:9811 W CHARLESTON BLVD STE 2538
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-7528
Practice Address - Country:US
Practice Address - Phone:702-505-3635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-22
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9005056211Medicaid
NV1710295860Medicaid