Provider Demographics
NPI:1154798916
Name:THE BRIDGE CLINIC OF ROCKOFRD
Entity type:Organization
Organization Name:THE BRIDGE CLINIC OF ROCKOFRD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-494-1594
Mailing Address - Street 1:PO BOX 16024
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61132-6024
Mailing Address - Country:US
Mailing Address - Phone:815-494-1594
Mailing Address - Fax:866-506-0931
Practice Address - Street 1:318 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-1006
Practice Address - Country:US
Practice Address - Phone:815-494-1594
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care