Provider Demographics
NPI:1184136400
Name:COMMUNITY BRIDGES, INC.
Entity type:Organization
Organization Name:COMMUNITY BRIDGES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOGEBOOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-831-7566
Mailing Address - Street 1:1855 W BASELINE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-9098
Mailing Address - Country:US
Mailing Address - Phone:480-831-7566
Mailing Address - Fax:480-831-7563
Practice Address - Street 1:824 N 99TH AVE STE 105
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-5327
Practice Address - Country:US
Practice Address - Phone:623-907-1457
Practice Address - Fax:623-755-2424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-26
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5274323P00000X
320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ325351Medicaid