NPIMap

Organization Active NPI

Community Bridges South, Inc.

  • Intellectual Disabilities Intermediate Care Facility
  • Ruston, LA
National Provider Identifier
1477689867
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
1037 Issued in LA
Legal business name
COMMUNITY BRIDGES SOUTH, INC.
Doing business as
Trace Drive Residence
Practice address
150 Trace Dr
Ruston, LA 71270-3449
Phone
(318) 255-1937
Fax
(318) 255-8233
NPI assigned
Feb 27, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Mike L. Reynolds
Title
Ceo
Phone
(318) 255-1937

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X 1037 LA Primary

Addresses

Primary practice location

150 Trace Dr
Ruston, LA 71270-3449

Mailing address

PO Box 715
Ruston, LA 71273-0715
Phone (318) 255-1937

Other identifiers 1

IdentifierTypeStateIssuer
1710229MedicaidLA

Other names 1

  • Trace Drive Residence Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

Intermediate care facility for individuals with intellectual disabilities certification: CCN 19G183

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
Trace Drive Home
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
Sep 10, 1985
Last certification
May 28, 2025
Beds
8
Ownership / control type
Private (proprietary)
Facility address
150 Trace Drive
Ruston, LA 71270

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
19D1058149Community Bridges South Trace Home150 Trace Drive, Ruston, LA 71270Certificate of waiverAug 29, 2026

National Provider Directory

National Provider Directory
Tax ID family
Community Bridges South Inc14 organizations share this tax ID, including this one

Other organizations with this tax ID 13

Organizations that report the same tax identification number in the National Provider Directory.

View all 13

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1172534400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1477689867",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 715",
            "city": "RUSTON",
            "state": "LA",
            "postal_code": "712730715",
            "telephone_number": "318-255-1937",
            "fax_number": "318-255-8233"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "150 TRACE DR",
            "city": "RUSTON",
            "state": "LA",
            "postal_code": "712703449",
            "telephone_number": "318-255-1937",
            "fax_number": "318-255-8233"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY BRIDGES SOUTH, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-27",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "REYNOLDS",
        "authorized_official_first_name": "MIKE",
        "authorized_official_middle_name": "L.",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "318-255-1937",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "LA",
            "license": "1037",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1710229",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Trace Drive Residence",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ruston, LA

Sources for this page

Verify at the official NPI Registry.