Provider Demographics
NPI:1194561670
Name:BRIDGE CLINIC, PLLC
Entity type:Organization
Organization Name:BRIDGE CLINIC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:KENWORTHY
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:435-313-7237
Mailing Address - Street 1:230 N 1680 E STE N1
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-2596
Mailing Address - Country:US
Mailing Address - Phone:435-313-7237
Mailing Address - Fax:
Practice Address - Street 1:230 N 1680 E STE N1
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2596
Practice Address - Country:US
Practice Address - Phone:435-313-7237
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-03
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care