Provider Demographics
NPI:1578086542
Name:FAITH & LOVE CONNECTION CENTER
Entity Type:Organization
Organization Name:FAITH & LOVE CONNECTION CENTER
Other - Org Name:FAITH & LOVE CONNECTION CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-791-9014
Mailing Address - Street 1:PO BOX 2574
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 S. SCALES STREET
Practice Address - Street 2:SUITE 201
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-2732
Practice Address - Country:US
Practice Address - Phone:336-791-9014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-21
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC=========Medicaid