NPIMap

Organization Active NPI

Community Bridges South

  • Intellectual Disabilities Intermediate Care Facility
  • Ruston, LA
National Provider Identifier
1770619876
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
1010 Issued in LA
Legal business name
COMMUNITY BRIDGES SOUTH
Doing business as
Benton Street Home
Practice address
1400 Benton St
Ruston, LA 71270-5404
Phone
(318) 255-1937
Fax
(318) 255-8233
NPI assigned
Feb 26, 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. Michael L Reynolds
Title
Ceo
Phone
(318) 255-1937

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X 1010 LA Primary

Addresses

Primary practice location

1400 Benton St
Ruston, LA 71270-5404

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
1710008MedicaidLA

Other names 1

  • Benton Street Home 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 19G271

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
Benton Street Home
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
Aug 22, 1988
Last certification
Feb 20, 2025
Beds
8
Ownership / control type
Private (proprietary)
Facility address
1400 Benton Street
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
19D1045390Community Bridges South Benton Street Home1400 Benton Street, Ruston, LA 71270Certificate of waiverSep 13, 2027

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": "1172448000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1770619876",
    "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": "1400 BENTON ST",
            "city": "RUSTON",
            "state": "LA",
            "postal_code": "712705404",
            "telephone_number": "318-255-1937",
            "fax_number": "318-255-8233"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "COMMUNITY BRIDGES SOUTH",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-26",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "REYNOLDS",
        "authorized_official_first_name": "MICHAEL",
        "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": "1010",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1710008",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Benton Street Home",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ruston, LA

Sources for this page

Verify at the official NPI Registry.