Healthcare Provider Details

I. General information

NPI: 1871672295
Provider Name (Legal Business Name): FREE WILL BAPTIST FAMILY MINISTRIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 VIRGINIA AVE NW
NORTON VA
24273-1919
US

IV. Provider business mailing address

844 VIRGINIA AVE NW
NORTON VA
24273-1919
US

V. Phone/Fax

Practice location:
  • Phone: 276-679-7284
  • Fax: 276-670-0060
Mailing address:
  • Phone: 276-679-7284
  • Fax: 276-670-0060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberSS-139-05
License Number StateVA

VIII. Authorized Official

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