Provider Demographics
NPI:1801245105
Name:YOUTH BRIDGE
Entity type:Organization
Organization Name:YOUTH BRIDGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MHP
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-575-9471
Mailing Address - Street 1:5327 CRESTWOOD ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-9292
Mailing Address - Country:US
Mailing Address - Phone:870-688-9651
Mailing Address - Fax:
Practice Address - Street 1:5327 CRESTWOOD ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-9292
Practice Address - Country:US
Practice Address - Phone:870-688-9651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171M00000X261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service