Provider Demographics
NPI:1699900431
Name:BREAD OF LIFE YOUTH & FAMILY SERVICES
Entity type:Organization
Organization Name:BREAD OF LIFE YOUTH & FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKENEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-248-0514
Mailing Address - Street 1:4401 E INDEPENDENCE BLVD STE 201B
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-0500
Mailing Address - Country:US
Mailing Address - Phone:704-248-0514
Mailing Address - Fax:
Practice Address - Street 1:4401 E INDEPENDENCE BLVD STE 201B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-0500
Practice Address - Country:US
Practice Address - Phone:704-248-0500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-22
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006916Medicaid
NC8302913HMedicaid