Provider Demographics
NPI:1407681497
Name:LIFEBRIDGE
Entity type:Organization
Organization Name:LIFEBRIDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DYLAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-336-0144
Mailing Address - Street 1:188 HIGH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1181
Mailing Address - Country:US
Mailing Address - Phone:973-336-0144
Mailing Address - Fax:
Practice Address - Street 1:188 HIGH ST APT 2
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-1181
Practice Address - Country:US
Practice Address - Phone:973-336-0144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-07
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health