Provider Demographics
NPI:1275637423
Name:OUR FATHERS PLACE INC
Entity Type:Organization
Organization Name:OUR FATHERS PLACE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:LINTON
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:704-684-0197
Mailing Address - Street 1:256 EAST BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677
Mailing Address - Country:US
Mailing Address - Phone:704-872-0313
Mailing Address - Fax:704-872-7787
Practice Address - Street 1:256 EAST BROAD STREET
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677
Practice Address - Country:US
Practice Address - Phone:704-872-0313
Practice Address - Fax:704-872-7787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC320800000X, 322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Not Answered322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603681Medicaid
NC6603748Medicaid