Provider Demographics
NPI:1790297661
Name:THE BRIDGE RECOVERY CENTER
Entity Type:Organization
Organization Name:THE BRIDGE RECOVERY CENTER
Other - Org Name:THE BRIDGE RECOVERY CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:REGISTERED NURSE
Authorized Official - Prefix:
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:801-721-7882
Mailing Address - Street 1:356 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-2828
Mailing Address - Country:US
Mailing Address - Phone:435-313-1554
Mailing Address - Fax:
Practice Address - Street 1:98 N 6680 W
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:UT
Practice Address - Zip Code:84737-6138
Practice Address - Country:US
Practice Address - Phone:435-313-1554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty