Provider Demographics
NPI:1205092608
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:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
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 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:480-962-7671
Practice Address - Street 1:803 W MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-4993
Practice Address - Country:US
Practice Address - Phone:928-468-0022
Practice Address - Fax:928-468-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-05
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ252714323P00000X, 291U00000X, 324500000X, 343900000X
320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No291U00000XLaboratoriesClinical Medical Laboratory
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ252714Medicaid