Provider Demographics
NPI:1811449044
Name:BRIDGE OF HOPE
Entity type:Organization
Organization Name:BRIDGE OF HOPE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DECLUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-438-3733
Mailing Address - Street 1:400 N WASHINGTON
Mailing Address - Street 2:
Mailing Address - City:POTOSI
Mailing Address - State:MISSOURI
Mailing Address - Zip Code:63664
Mailing Address - Country:UM
Mailing Address - Phone:573-438-3733
Mailing Address - Fax:
Practice Address - Street 1:400 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1716
Practice Address - Country:US
Practice Address - Phone:573-438-3733
Practice Address - Fax:573-438-0046
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAITH FOUNDATION CHILDRENS HOME
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO30402638322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children