Healthcare Provider Details

I. General information

NPI: 1669529178
Provider Name (Legal Business Name): FREE WILL BAPTIST CHILDRENS HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7907 BUCK DEANS ROAD
MIDDLESEX NC
27557
US

IV. Provider business mailing address

PO BOX 249
MIDDLESEX NC
27557-0249
US

V. Phone/Fax

Practice location:
  • Phone: 252-235-2161
  • Fax: 252-235-2625
Mailing address:
  • Phone: 252-235-2161
  • Fax: 252-235-2625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberB00358
License Number StateNC

VIII. Authorized Official

Name: MR. GARY W LEE
Title or Position: PRESIDENT/CEO
Credential:
Phone: 252-235-2161