Organization
BREAD OF LIFE YOUTH & FAMILY SERVICES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
AHMAD BLAKENEY (OWNER)
(704) 248-0514
Entity
Organization
Contact information
Practice address
4401 E INDEPENDENCE BLVD STE 201B, CHARLOTTE, NC 28205-0500
(704) 248-0500
Mailing address
4401 E INDEPENDENCE BLVD STE 201B, CHARLOTTE, NC 28205-0500
(704) 248-0514
Taxonomy
Speciality
Code
Description
License number
State
251B00000X
Case Management Agency
—
—
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
6006916
—
NC
05
—
8302913H
—
NC
Enumeration date
05/22/2009
Last updated
11/05/2012
Update your record
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