Provider Demographics
NPI:1952512295
Name:BRADLEY HOME CARING FOR WAKE COMMUNITY AND CAROLINAS
Entity Type:Organization
Organization Name:BRADLEY HOME CARING FOR WAKE COMMUNITY AND CAROLINAS
Other - Org Name:KIMBERLY HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CORDELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:AKAGHA
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:919-772-9382
Mailing Address - Street 1:PO BOX 2055
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2055
Mailing Address - Country:US
Mailing Address - Phone:919-772-9382
Mailing Address - Fax:919-772-9382
Practice Address - Street 1:6420 MALIBU DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-4908
Practice Address - Country:US
Practice Address - Phone:919-772-9382
Practice Address - Fax:919-772-9382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-092-412320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities