Provider Demographics
NPI:1740340421
Name:BRIDGING TO SUCCESS
Entity type:Organization
Organization Name:BRIDGING TO SUCCESS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PHILOMENA
Authorized Official - Middle Name:CHIKA
Authorized Official - Last Name:DURU
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, MSN
Authorized Official - Phone:701-281-9281
Mailing Address - Street 1:345 BONANZA DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-9422
Mailing Address - Country:US
Mailing Address - Phone:704-637-7562
Mailing Address - Fax:
Practice Address - Street 1:223 WEST 12TH
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-3507
Practice Address - Country:US
Practice Address - Phone:704-637-7562
Practice Address - Fax:704-636-0075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
322D00000X
NCMHL-080-139322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604266Medicaid