Provider Demographics
NPI:1194295089
Name:FREEDOM BRIDGE TO RECOVERY LLC
Entity type:Organization
Organization Name:FREEDOM BRIDGE TO RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:HENDERSHOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-791-9943
Mailing Address - Street 1:1307 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3050
Mailing Address - Country:US
Mailing Address - Phone:270-791-9943
Mailing Address - Fax:270-904-2377
Practice Address - Street 1:1307 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3050
Practice Address - Country:US
Practice Address - Phone:270-791-9943
Practice Address - Fax:270-904-2377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-04
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1194295089Medicaid