Provider Demographics
NPI:1881866002
Name:EBENEZER CHRISTIAN CHILDRENS HOME
Entity Type:Organization
Organization Name:EBENEZER CHRISTIAN CHILDRENS HOME
Other - Org Name:EBENEZER GARDEN CHRISTIAN CHILDRENS HOME
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-667-5683
Mailing Address - Street 1:P.O. BOX 2777
Mailing Address - Street 2:
Mailing Address - City:NORTH WILKESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28659-2777
Mailing Address - Country:US
Mailing Address - Phone:336-667-5683
Mailing Address - Fax:336-667-8634
Practice Address - Street 1:1006 BYRD RIDGE RD
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-8044
Practice Address - Country:US
Practice Address - Phone:336-667-5683
Practice Address - Fax:336-667-8634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-097-061322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children