MEDICARE: BREAD OF LIFE PEDIATRICS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician

General Provider Information

NPI Number	:	1053003368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BREAD OF LIFE PEDIATRICS PLLC

Provider Business Mailing Address
First Line	:	13111 WESTHEIMER RD STE 250
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77077-5520
Country	:	US
Telephone Number	:	832-866-0919
Fax Number	:	832-202-0808

Provider Business Practice Location Address
First Line	:	13111 WESTHEIMER RD STE 250
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77077-5520
Country	:	US
Telephone Number	:	832-866-0919
Fax Number	:	832-202-0808

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. EVELYN OKERULU
Credential	:
Telephone Number	:	832-866-0919

Provider Enumeration Date	:	05/24/2023
Last Update Date	:	01/10/2024

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