| Bridgeway Recovery Center, Llc | |
|
1102 Williams St Valdosta GA 31601-4041 | |
| (850) 348-7225 | |
| (229) 506-6877 |
| Full Name | Bridgeway Recovery Center, Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 1102 Williams St, Valdosta, Georgia |
| Authorized Official Name and Position | Kermit L Elliott (CEO) |
| Authorized Official Contact | 8503487225 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Bridgeway Recovery Center, Llc 1102 Williams St Valdosta GA 31601-4041 Ph: (850) 348-7225 | Bridgeway Recovery Center, Llc 1102 Williams St Valdosta GA 31601-4041 Ph: (850) 348-7225 |
| NPI Number | 1821610452 |
|---|---|
| Provider Enumeration Date | 05/18/2020 |
| Last Update Date | 05/18/2020 |
| Certification Date | 05/18/2020 |
| Medicare PECOS PAC ID | 5991126567 |
|---|---|
| Medicare Enrollment ID | O20200608000634 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1821610452 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Secondary |
| 261Q00000X | Clinic/center | (* (Not Available)) | Primary |
| Provider Name | Robert E Bryan |
|---|---|
| Provider Type | Practitioner - Addiction Medicine |
| Provider Identifiers | NPI Number: 1609090141 PECOS PAC ID: 0840241832 Enrollment ID: I20080131000300 |
| Provider Name | Kelly D Jones |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1023275757 PECOS PAC ID: 5890977383 Enrollment ID: I20110303001002 |
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