Provider Demographics
NPI:1568622009
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: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:
Authorized Official - Phone:910-904-5791
Mailing Address - Street 1:PO BOX 26073
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-5017
Mailing Address - Country:US
Mailing Address - Phone:910-904-5791
Mailing Address - Fax:910-904-6791
Practice Address - Street 1:105 HARVEST LN
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-6516
Practice Address - Country:US
Practice Address - Phone:910-904-5791
Practice Address - Fax:910-904-6791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL047074322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children