Provider Demographics
NPI:1912652454
Name:BRIDGE ROAD PRIMARY CARE
Entity Type:Organization
Organization Name:BRIDGE ROAD PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:D
Authorized Official - Last Name:GUNNOE
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:304-437-9705
Mailing Address - Street 1:1545 BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-1949
Mailing Address - Country:US
Mailing Address - Phone:304-437-9705
Mailing Address - Fax:
Practice Address - Street 1:1545 BRIDGE RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-1949
Practice Address - Country:US
Practice Address - Phone:304-437-9705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center