Provider Demographics
NPI:1154859767
Name:BREAD OF LIFE HEALTHCARE
Entity Type:Organization
Organization Name:BREAD OF LIFE HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KUNESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-484-4395
Mailing Address - Street 1:2 CITYPLACE DR RM 258
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7096
Mailing Address - Country:US
Mailing Address - Phone:314-812-2757
Mailing Address - Fax:
Practice Address - Street 1:2 CITYPLACE DR RM 258
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7096
Practice Address - Country:US
Practice Address - Phone:314-812-2757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health