Provider Demographics
NPI:1871637009
Name:RECOVERY BRIDGE
Entity Type:Organization
Organization Name:RECOVERY BRIDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:K
Authorized Official - Last Name:BOBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-255-5999
Mailing Address - Street 1:7679 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-7107
Mailing Address - Country:US
Mailing Address - Phone:801-255-5999
Mailing Address - Fax:801-255-0822
Practice Address - Street 1:7679 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-7107
Practice Address - Country:US
Practice Address - Phone:801-255-5999
Practice Address - Fax:801-255-0822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT138930-6006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========OtherTIN