Provider Demographics
NPI:1962862987
Name:BRIDGE BACK TO LIFE
Entity Type:Organization
Organization Name:BRIDGE BACK TO LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-679-4960
Mailing Address - Street 1:500 8TH AVE RM 906
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018-4190
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 8TH AVE RM 906
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-4190
Practice Address - Country:US
Practice Address - Phone:212-679-4960
Practice Address - Fax:212-399-5444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children