Provider Demographics
NPI:1003042904
Name:WORD OF LIFE OUTREACH OF CAPE FEAR, INC.
Entity Type:Organization
Organization Name:WORD OF LIFE OUTREACH OF CAPE FEAR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:910-547-8792
Mailing Address - Street 1:PO BOX 717
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-0717
Mailing Address - Country:US
Mailing Address - Phone:910-371-5300
Mailing Address - Fax:910-371-5302
Practice Address - Street 1:10225 BLACKWELL RD SE
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-8515
Practice Address - Country:US
Practice Address - Phone:910-371-5300
Practice Address - Fax:910-371-5302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-05
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301346HMedicaid