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General NPI Number Information
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NPI Number | 1396285433
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Entity Type | Organization
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Legal Business Name | BREAD OF LIFE CDS LLC
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Dates
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Enumeration Date | 03/07/2017
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Last Update Date | 03/07/2017
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Provider Practice Location Address
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Address Line | 3029 SAINT VINCENT AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63104-1421
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Country | US
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Telephone | 314-874-9616
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Fax | 314-000-0000
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Provider Business Mailing Address
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Address Line | 3029 SAINT VINCENT AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63104-1421
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Country | US
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Telephone | 314-874-9616
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Fax | 314-000-0000
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Authorized Official
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Title or Position | DIRECTOR
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Name | DELORES BINGHAM
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Credential |
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Telephone | 314-874-9616
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State | MO
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