Provider Demographics
NPI:1710022918
Name:BAPTIST HOUSE AT BETHABARA
Entity Type:Organization
Organization Name:BAPTIST HOUSE AT BETHABARA
Other - Org Name:BAPTIST CHILDREN'S HOMES OF NC, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:C.
Authorized Official - Middle Name:F
Authorized Official - Last Name:MCDOWELL
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:336-474-1260
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27361-0338
Mailing Address - Country:US
Mailing Address - Phone:336-474-1260
Mailing Address - Fax:336-472-8157
Practice Address - Street 1:4643 OLD TOWN DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-2616
Practice Address - Country:US
Practice Address - Phone:336-727-1973
Practice Address - Fax:336-727-1547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCA034057320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804105Medicaid