Provider Demographics
NPI:1790893675
Name:BRIDGE OF LIGHT HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:BRIDGE OF LIGHT HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXCEUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BOSCHULTE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:614-751-3730
Mailing Address - Street 1:2234 S HAMILTON RD
Mailing Address - Street 2:101
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43232-4389
Mailing Address - Country:US
Mailing Address - Phone:614-751-3730
Mailing Address - Fax:614-751-4481
Practice Address - Street 1:2234 S HAMILTON RD
Practice Address - Street 2:101
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43232-4389
Practice Address - Country:US
Practice Address - Phone:614-751-3730
Practice Address - Fax:614-751-4481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2535395Medicaid
OH2535395Medicaid