Provider Demographics
NPI:1508103441
Name:BREATHE NEW LIFE, LLC.
Entity Type:Organization
Organization Name:BREATHE NEW LIFE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:PURNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-597-7323
Mailing Address - Street 1:4311 BROWN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-1321
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4311 BROWN ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-1321
Practice Address - Country:US
Practice Address - Phone:267-597-7323
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 320900000X
PA302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251E00000XAgenciesHome Health
No302R00000XManaged Care OrganizationsHealth Maintenance Organization