Healthcare Provider Details

I. General information

NPI: 1861740904
Provider Name (Legal Business Name): BREAD OF LIFE ASSISTED LIVING CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 MARTIN LUTHER KING JR DR SW SUITE 450-A
ATLANTA GA
30310-1101
US

IV. Provider business mailing address

2001 MARTIN LUTHER KING JR DR SW SUITE 450-A
ATLANTA GA
30310-1101
US

V. Phone/Fax

Practice location:
  • Phone: 678-732-8191
  • Fax: 404-564-6487
Mailing address:
  • Phone: 678-732-8191
  • Fax: 404-564-6487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number StateGA

VIII. Authorized Official

Name: MRS. CHRISTINE NWANKWO
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 678-732-8191