Provider Demographics
NPI:1447904842
Name:BRIDGE OF LIGHT
Entity type:Organization
Organization Name:BRIDGE OF LIGHT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:XANDER
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:FAISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-568-1338
Mailing Address - Street 1:14300 N PENNSYLVANIA AVE APT 326
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-6063
Mailing Address - Country:US
Mailing Address - Phone:405-568-1338
Mailing Address - Fax:
Practice Address - Street 1:14300 N PENNSYLVANIA AVE APT 326
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-6063
Practice Address - Country:US
Practice Address - Phone:405-568-1338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-05
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome HealthGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty