Provider Demographics
NPI:1821610452
Name:BRIDGEWAY RECOVERY CENTER, LLC
Entity Type:Organization
Organization Name:BRIDGEWAY RECOVERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KERMIT
Authorized Official - Middle Name:L
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:850-348-7225
Mailing Address - Street 1:1102 WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-4041
Mailing Address - Country:US
Mailing Address - Phone:850-348-7225
Mailing Address - Fax:
Practice Address - Street 1:1102 WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-4041
Practice Address - Country:US
Practice Address - Phone:850-348-7225
Practice Address - Fax:229-506-6877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty