Basic Information
| Provider Information | |||||||||
| NPI: | 1992971410 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRIDGEWAY CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 137 HOSPITAL DR NE | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325485063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508337400 | ||||||||
| FaxNumber: | 8508337434 | ||||||||
| Practice Location | |||||||||
| Address1: | 137 HOSPITAL DR NE | ||||||||
| Address2: | |||||||||
| City: | FORT WALTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325485063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508337400 | ||||||||
| FaxNumber: | 8508337434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2008 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | BARLOW | ||||||||
| AuthorizedOfficialFirstName: | BONNIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8508333975 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 060398802 | 05 | FL | MEDICAID |