Healthcare Provider Details

I. General information

NPI: 1538269915
Provider Name (Legal Business Name): FREE WILL BAPTIST FAMILY MINISTRIES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15149 OLD JONESBORO ROAD
BRISTOL VA
24202-4623
US

IV. Provider business mailing address

90 STANLEY LANE
GREENEVILLE TN
37743
US

V. Phone/Fax

Practice location:
  • Phone: 276-466-5051
  • Fax: 276-466-5045
Mailing address:
  • Phone: 423-639-9449
  • Fax: 423-639-5083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberSS-304-06
License Number StateVA

VIII. Authorized Official

Name: DR. JAMES KILGORE
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: PH.D
Phone: 423-639-9449