Provider Demographics
NPI:1346303187
Name:OUR FATHERS PLACE INC
Entity Type:Organization
Organization Name:OUR FATHERS PLACE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:LINTON
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:704-684-0197
Mailing Address - Street 1:256 EAST BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-5325
Mailing Address - Country:US
Mailing Address - Phone:704-872-0313
Mailing Address - Fax:704-872-7787
Practice Address - Street 1:413 STOCKTON STREET
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-5325
Practice Address - Country:US
Practice Address - Phone:704-872-0313
Practice Address - Fax:704-872-7787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL049093322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603681Medicaid