Provider Demographics
NPI:1790156628
Name:FAITH HARBOR
Entity Type:Organization
Organization Name:FAITH HARBOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:LYNNETTE
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:SCL, IPD
Authorized Official - Phone:270-781-4050
Mailing Address - Street 1:PO BOX 151
Mailing Address - Street 2:
Mailing Address - City:ROCKFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42274-0151
Mailing Address - Country:US
Mailing Address - Phone:270-781-4050
Mailing Address - Fax:270-781-4099
Practice Address - Street 1:1268 CAMPBELL LN STE 101
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-1034
Practice Address - Country:US
Practice Address - Phone:270-781-4050
Practice Address - Fax:270-781-4099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251B00000XAgenciesCase Management
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child