Provider Demographics
NPI:1134226608
Name:WAYNE COUNTY FAMILY LIFE RESIDENTIAL HOME
Entity type:Organization
Organization Name:WAYNE COUNTY FAMILY LIFE RESIDENTIAL HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN- DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RN-081918
Authorized Official - Phone:919-736-9605
Mailing Address - Street 1:200 PERRY DR.
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530
Mailing Address - Country:US
Mailing Address - Phone:919-734-0617
Mailing Address - Fax:
Practice Address - Street 1:514 FOREST HILL DR.
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27533-0296
Practice Address - Country:US
Practice Address - Phone:919-736-9605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-096-177322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMHL-096-177Other1300- LEVEL II GROUP HOME