Provider Demographics
NPI:1760933154
Name:COMMUNITY BRIDGES, INC.
Entity Type:Organization
Organization Name:COMMUNITY BRIDGES, INC.
Other - Org Name:HOLBROOK OUTPATIENT SERVICES CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOGEBOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-831-7566
Mailing Address - Street 1:1855 W BASELINE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-9098
Mailing Address - Country:US
Mailing Address - Phone:480-831-7566
Mailing Address - Fax:
Practice Address - Street 1:993 HERMOSA DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:HOLBROOK
Practice Address - State:AZ
Practice Address - Zip Code:86025
Practice Address - Country:US
Practice Address - Phone:928-524-1151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7809251B00000X
251S00000X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOTC7166OtherLICENSE