Provider Demographics
NPI:1780316489
Name:AGAPE LIFE PREVENTION CENTER
Entity type:Organization
Organization Name:AGAPE LIFE PREVENTION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PREVENTION SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TIARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-437-7350
Mailing Address - Street 1:6691 CHURCH ST # 960843
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2213
Mailing Address - Country:US
Mailing Address - Phone:678-437-7350
Mailing Address - Fax:
Practice Address - Street 1:6071 HIGHWAY 85 APT 31A
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-1531
Practice Address - Country:US
Practice Address - Phone:678-437-7350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No174200000XOther Service ProvidersMeals
No251B00000XAgenciesCase Management
No251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000000Medicaid