Provider Demographics
NPI:1104126572
Name:BRIDGE OF HOPE OF CENTRAL FLORIDA CORP
Entity type:Organization
Organization Name:BRIDGE OF HOPE OF CENTRAL FLORIDA CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:407-575-4636
Mailing Address - Street 1:PO BOX 452878
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34745-2878
Mailing Address - Country:US
Mailing Address - Phone:407-575-4636
Mailing Address - Fax:407-343-5599
Practice Address - Street 1:1300 KEVSTIN DR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-5843
Practice Address - Country:US
Practice Address - Phone:407-575-4636
Practice Address - Fax:321-250-7425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 24417261QP2000X
FLOT 11560261QX0100X
FLSA 8292261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000867500Medicaid
FL000867503Medicaid
FL000867501Medicaid
FL000867502Medicaid