Healthcare Provider Details

I. General information

NPI: 1790156628
Provider Name (Legal Business Name): FAITH HARBOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1268 CAMPBELL LN STE 101
BOWLING GREEN KY
42104-1034
US

IV. Provider business mailing address

PO BOX 151
ROCKFIELD KY
42274-0151
US

V. Phone/Fax

Practice location:
  • Phone: 270-781-4050
  • Fax: 270-781-4099
Mailing address:
  • Phone: 270-781-4050
  • Fax: 270-781-4099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANGEL LYNNETTE LEE
Title or Position: OWNER/EXECUTIVE DIRECTOR
Credential: SCL, IPD
Phone: 270-781-4050