Provider Demographics
NPI:1861683542
Name:BRIDGES CLUBHOUSE
Entity Type:Organization
Organization Name:BRIDGES CLUBHOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERN
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-463-1891
Mailing Address - Street 1:2105 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033-1524
Mailing Address - Country:US
Mailing Address - Phone:803-796-6179
Mailing Address - Fax:
Practice Address - Street 1:2105 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:CAYCE
Practice Address - State:SC
Practice Address - Zip Code:29033-1524
Practice Address - Country:US
Practice Address - Phone:803-796-6179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MENTAL HEALTH AMERICA OF SOUTH CAROLINA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)