Provider Demographics
NPI:1952446619
Name:WORD OF LIFE OUTEACH, INC
Entity Type:Organization
Organization Name:WORD OF LIFE OUTEACH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:B A
Authorized Official - Phone:910-371-5300
Mailing Address - Street 1:PO BOX 661
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-0661
Mailing Address - Country:US
Mailing Address - Phone:910-371-5300
Mailing Address - Fax:910-371-5302
Practice Address - Street 1:9781 BLACKWELL RD SE
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-8519
Practice Address - Country:US
Practice Address - Phone:910-371-5300
Practice Address - Fax:910-371-5302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251B00000X
NCMHL-010-045322D00000X
NCMHL-010-048322D00000X
NCMHL-010-049322D00000X
NCMHL-065-164322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251B00000XAgenciesCase Management
Not Answered322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301346Medicaid
NC6603769Medicaid
NC6603477Medicaid
NC6603942Medicaid
NC6603673Medicaid