Provider Demographics
NPI:1053495523
Name:TRINITY WILL GROUP
Entity Type:Organization
Organization Name:TRINITY WILL GROUP
Other - Org Name:JIREH HAVEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:MELINDA
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-525-5035
Mailing Address - Street 1:PO BOX 618
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28329-0618
Mailing Address - Country:US
Mailing Address - Phone:910-590-2971
Mailing Address - Fax:910-596-2971
Practice Address - Street 1:140 FAULKNER LN
Practice Address - Street 2:
Practice Address - City:ROSEBORO
Practice Address - State:NC
Practice Address - Zip Code:28382-5415
Practice Address - Country:US
Practice Address - Phone:910-525-5035
Practice Address - Fax:910-525-5065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL082046322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603564Medicaid