Provider Demographics
NPI:1154156222
Name:BRIDGE OF HOPE WELLNESS LLC
Entity type:Organization
Organization Name:BRIDGE OF HOPE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:O'DELL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:910-297-6430
Mailing Address - Street 1:47 COMBINE LN SE
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-9651
Mailing Address - Country:US
Mailing Address - Phone:910-297-6430
Mailing Address - Fax:
Practice Address - Street 1:1001 MAIN STREET
Practice Address - Street 2:SUITE A
Practice Address - City:FAIR BLUFF
Practice Address - State:NC
Practice Address - Zip Code:28439
Practice Address - Country:US
Practice Address - Phone:910-632-0234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-06
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty