Provider Demographics
NPI:1922364157
Name:COMMUNITY BRIDGES, INC
Entity Type:Organization
Organization Name:COMMUNITY BRIDGES, INC
Other - Org Name:CASA GRANDE OUTP SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP/COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOGEBOOM
Authorized Official - Suffix:
Authorized Official - Credentials:LISAC
Authorized Official - Phone:480-831-7566
Mailing Address - Street 1:1855 W BASELINE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-9000
Mailing Address - Country:US
Mailing Address - Phone:480-831-7566
Mailing Address - Fax:480-962-7671
Practice Address - Street 1:675 E COTTONWOOD LN
Practice Address - Street 2:SUITE 101
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-2032
Practice Address - Country:US
Practice Address - Phone:520-426-0088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY BRIDGES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ03D2036422291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory