Provider Demographics
NPI:1952104622
Name:VITA BRIDGE HEALTH LLC
Entity type:Organization
Organization Name:VITA BRIDGE HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN/PMHNP
Authorized Official - Prefix:
Authorized Official - First Name:OLAJUMOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONGBO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-207-0296
Mailing Address - Street 1:15150 W PARK PL FL 2
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2385
Mailing Address - Country:US
Mailing Address - Phone:480-207-0296
Mailing Address - Fax:
Practice Address - Street 1:15150 W PARK PL FL 2
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2385
Practice Address - Country:US
Practice Address - Phone:480-207-0296
Practice Address - Fax:480-546-3290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-28
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service