Provider Demographics
NPI:1558708669
Name:BRIDGES BTC
Entity type:Organization
Organization Name:BRIDGES BTC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:COOKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-690-3464
Mailing Address - Street 1:1694 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3131
Mailing Address - Country:US
Mailing Address - Phone:321-690-3464
Mailing Address - Fax:321-690-3467
Practice Address - Street 1:1694 CEDAR ST
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3131
Practice Address - Country:US
Practice Address - Phone:321-690-3464
Practice Address - Fax:321-690-3467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16168251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024164496Medicaid