1780875138 NPI number — THREE FORKS HOME

Table of content: (NPI 1780875138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780875138 NPI number — THREE FORKS HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THREE FORKS HOME
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:
Provider Other Organization Name Type Code:
6
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:
1780875138
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 338
Provider Second Line Business Mailing Address:
BAPTIST CHILDREN'S HOMES OF NC, INC
Provider Business Mailing Address City Name:
THOMASVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27361-0338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-474-1260
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
392 CAMP JOY ROAD
Provider Second Line Business Practice Location Address:
THREE FORKS HOME
Provider Business Practice Location Address City Name:
ZIONVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28698-9759
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-350-1254
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCDOWELL
Authorized Official First Name:
C.
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
EXECUTIVE VICE PRESIDENT
Authorized Official Telephone Number:
336-474-1260

Provider Taxonomy Codes

  • Taxonomy code: 320600000X , with the licence number:  MHL 095 043 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MHL 095-043 . This is a "STATE LICENSE NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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