Provider Demographics
NPI:1760618458
Name:BRIDGE TO HEALTH, LLC
Entity Type:Organization
Organization Name:BRIDGE TO HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GROESSL
Authorized Official - Suffix:
Authorized Official - Credentials:MSN
Authorized Official - Phone:920-434-8500
Mailing Address - Street 1:2149 VELP AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-5424
Mailing Address - Country:US
Mailing Address - Phone:920-434-8500
Mailing Address - Fax:920-468-9791
Practice Address - Street 1:2149 VELP AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-5424
Practice Address - Country:US
Practice Address - Phone:920-434-8500
Practice Address - Fax:920-468-9791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI79614163WP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0000XNursing Service ProvidersRegistered NursePain ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43845200Medicaid
WI43845200Medicaid
WI000007835Medicare PIN