Provider Demographics
NPI:1356969406
Name:B BRIDGE BACK LLC
Entity type:Organization
Organization Name:B BRIDGE BACK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIMITRY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIKTEREV
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:844-877-2440
Mailing Address - Street 1:314 MCHENRY RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-2428
Mailing Address - Country:US
Mailing Address - Phone:844-877-2440
Mailing Address - Fax:
Practice Address - Street 1:1655 N ARLINGTON HEIGHTS RD STE 305
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-3982
Practice Address - Country:US
Practice Address - Phone:844-427-6739
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-06
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty