Provider Demographics
NPI:1710392220
Name:BRIDGES HABILITATION SERVICES, INC.
Entity Type:Organization
Organization Name:BRIDGES HABILITATION SERVICES, INC.
Other - Org Name:BRIDGES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:CANEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:307-789-0664
Mailing Address - Street 1:PO BOX 1642
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82931-1642
Mailing Address - Country:US
Mailing Address - Phone:307-789-0664
Mailing Address - Fax:307-789-1902
Practice Address - Street 1:400 S KENDRICK AVE
Practice Address - Street 2:SUITE 201D
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3848
Practice Address - Country:US
Practice Address - Phone:307-685-7105
Practice Address - Fax:307-222-0614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1245305804Medicaid
WY1245305804Medicaid