Healthcare Provider Details

I. General information

NPI: 1396285433
Provider Name (Legal Business Name): BREAD OF LIFE CDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3029 SAINT VINCENT AVE
SAINT LOUIS MO
63104-1421
US

IV. Provider business mailing address

3029 SAINT VINCENT AVE
SAINT LOUIS MO
63104-1421
US

V. Phone/Fax

Practice location:
  • Phone: 314-874-9616
  • Fax: 314-000-0000
Mailing address:
  • Phone: 314-874-9616
  • Fax: 314-000-0000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateMO

VIII. Authorized Official

Name: DELORES BINGHAM
Title or Position: DIRECTOR
Credential:
Phone: 314-874-9616