Provider Demographics
NPI:1346315595
Name:FRIDAY'S PLACE, INC.
Entity Type:Organization
Organization Name:FRIDAY'S PLACE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:FRIDAY
Authorized Official - Suffix:
Authorized Official - Credentials:QMHP
Authorized Official - Phone:704-864-0366
Mailing Address - Street 1:PO BOX 2212
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28053-2212
Mailing Address - Country:US
Mailing Address - Phone:704-864-0366
Mailing Address - Fax:704-864-0311
Practice Address - Street 1:811 S OAKLAND ST STE A
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0472
Practice Address - Country:US
Practice Address - Phone:704-864-0366
Practice Address - Fax:704-864-0311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6005964101YM0800X
NC59091132084P0804X
NC8300372251B00000X, 251S00000X
NC3408063251C00000X, 385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, ChildGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408063Medicaid
NC8300372GMedicaid
NC8300372HMedicaid
NC5909113Medicaid
NC8300372Medicaid
NC6005964Medicaid
NC8300372BMedicaid