Provider Demographics
NPI:1861740904
Name:BREAD OF LIFE ASSISTED LIVING CORPORATION
Entity type:Organization
Organization Name:BREAD OF LIFE ASSISTED LIVING CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:NWANKWO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-732-8191
Mailing Address - Street 1:2001 MARTIN LUTHER KING JR DR SW
Mailing Address - Street 2:SUITE 450-A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-1101
Mailing Address - Country:US
Mailing Address - Phone:678-732-8191
Mailing Address - Fax:404-564-6487
Practice Address - Street 1:2001 MARTIN LUTHER KING JR DR SW
Practice Address - Street 2:SUITE 450-A
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-1101
Practice Address - Country:US
Practice Address - Phone:678-732-8191
Practice Address - Fax:404-564-6487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251B00000X, 251J00000X, 3104A0630X, 3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No251B00000XAgenciesCase Management
No251J00000XAgenciesNursing Care
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances