Provider Demographics
NPI:1982815221
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:BRADLEY HOME
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:
Mailing Address - Fax:
Practice Address - Street 1:1505 KELLY RD
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-4107
Practice Address - Country:US
Practice Address - Phone:919-772-0053
Practice Address - Fax:
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-092-319320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7803935Medicaid
NC7803512Medicaid
NC7805168Medicaid