Provider Demographics
NPI:1487784146
Name:MISTYISLE BRIDGE. INC
Entity type:Organization
Organization Name:MISTYISLE BRIDGE. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-226-1153
Mailing Address - Street 1:PO BOX 605
Mailing Address - Street 2:
Mailing Address - City:CLARION
Mailing Address - State:PA
Mailing Address - Zip Code:16214-0605
Mailing Address - Country:US
Mailing Address - Phone:814-226-1153
Mailing Address - Fax:814-226-1156
Practice Address - Street 1:9664 ROUTE 322
Practice Address - Street 2:
Practice Address - City:SHIPPENVILLE
Practice Address - State:PA
Practice Address - Zip Code:16254-8734
Practice Address - Country:US
Practice Address - Phone:814-226-1153
Practice Address - Fax:814-226-1156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA424960251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012740580001Medicaid