Organization
BRIDGEWAY INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
WILLIAM NELSON (CEO)
(309) 344-2323
Entity
Organization
Contact information
Practice address
2079 EDGEWATER DR, PEKIN, IL 61554
(309) 382-2006
(309) 382-2007
Mailing address
2079 EDGEWATER DR, PEKIN, IL 61554-7833
(309) 382-2006
(309) 382-2007
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
04016
IL
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
04016
—
IL
01
—
AC 217/557-9285
MEDICARE CERTIFICATION
IL
Enumeration date
10/03/2011
Last updated
07/25/2022
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