Provider Demographics
NPI:1891172052
Name:BUILDING NEW BRIDGES, INC.
Entity Type:Organization
Organization Name:BUILDING NEW BRIDGES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEMETRIA (MIMI)
Authorized Official - Middle Name:CHARMAINE
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-207-7560
Mailing Address - Street 1:455 N MESA DR STE 11
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-5936
Mailing Address - Country:US
Mailing Address - Phone:480-207-7560
Mailing Address - Fax:480-668-3439
Practice Address - Street 1:455 N MESA DR STE 11
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-5936
Practice Address - Country:US
Practice Address - Phone:480-207-7560
Practice Address - Fax:480-668-3439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC6493261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ945592Medicaid