Provider Demographics
NPI:1225164171
Name:POTTER'S HOUSE OUTREACH CORPORATION
Entity Type:Organization
Organization Name:POTTER'S HOUSE OUTREACH CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:TERRELL
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:910-670-9121
Mailing Address - Street 1:100 WESTLAKE DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314
Mailing Address - Country:US
Mailing Address - Phone:910-867-7791
Mailing Address - Fax:910-867-7731
Practice Address - Street 1:100 WESTLAKE RD
Practice Address - Street 2:SUITE 104
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28314-1660
Practice Address - Country:US
Practice Address - Phone:910-867-7791
Practice Address - Fax:910-867-7731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management