Healthcare Provider Details

I. General information

NPI: 1780316489
Provider Name (Legal Business Name): AGAPE LIFE PREVENTION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6071 HIGHWAY 85 APT 31A
RIVERDALE GA
30274-1531
US

IV. Provider business mailing address

6691 CHURCH ST # 960843
RIVERDALE GA
30274-2213
US

V. Phone/Fax

Practice location:
  • Phone: 678-437-7350
  • Fax:
Mailing address:
  • Phone: 678-437-7350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: TIARA BRACEY
Title or Position: PREVENTION SPECIALIST
Credential:
Phone: 678-437-7350