1104961861 NPI number — WORD OF LIFE OUTREACH OF CAPE FEAR INC

Table of content: (NPI 1104961861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104961861 NPI number — WORD OF LIFE OUTREACH OF CAPE FEAR INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WORD OF LIFE OUTREACH OF CAPE FEAR INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WORD OF LIFE OUTREACH INC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104961861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 717
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LELAND
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28451-0717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-371-5300
Provider Business Mailing Address Fax Number:
910-371-5302

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10225 BLACKWELL RD SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LELAND
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-371-5300
Provider Business Practice Location Address Fax Number:
910-371-5302
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
JEFFERY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
910-371-5300

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YP2500X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TC2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251C00000X , with the licence number: 3418845 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: MHL-010-061 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253J00000X , with the licence number: 197 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8301346 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6603673 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6604291 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6603769 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6006100 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6603477 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6603942 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6604290 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8302371 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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