=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649449091
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAITH HOME, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/29/2008
-----------------------------------------------------
Last Update Date | 04/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 808 MYSTIC DR
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27406-5726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-856-0671
-----------------------------------------------------
Fax | 336-856-0671
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2501 DONLORA DR
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27407-6015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-854-1718
-----------------------------------------------------
Fax | 336-854-1718
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / DIRECTOR
-----------------------------------------------------
Name | MR. LEON HARLIE STURDIVANT SR.
-----------------------------------------------------
Credential | DIRECT OWNER (DO)
-----------------------------------------------------
Telephone | 336-854-1718
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | MHL041732
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------