Provider Demographics
NPI:1740556893
Name:KIDSBRIDGE
Entity Type:Organization
Organization Name:KIDSBRIDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:WIESE
Authorized Official - Suffix:
Authorized Official - Credentials:MA OTR/L
Authorized Official - Phone:505-908-0717
Mailing Address - Street 1:1104 SALAMANCA ST NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5626
Mailing Address - Country:US
Mailing Address - Phone:505-908-0717
Mailing Address - Fax:505-344-5553
Practice Address - Street 1:608 BLEDSOE RD NW
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107-6219
Practice Address - Country:US
Practice Address - Phone:505-908-0717
Practice Address - Fax:505-344-5553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2414261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1841473527OtherINDIVIDUAL NPI