Provider Demographics
NPI:1649449091
Name:FAITH HOME, INC.
Entity type:Organization
Organization Name:FAITH HOME, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:HARLIE
Authorized Official - Last Name:STURDIVANT
Authorized Official - Suffix:SR
Authorized Official - Credentials:DIRECT OWNER (DO)
Authorized Official - Phone:336-854-1718
Mailing Address - Street 1:2501 DONLORA DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-6015
Mailing Address - Country:US
Mailing Address - Phone:336-854-1718
Mailing Address - Fax:336-854-1718
Practice Address - Street 1:808 MYSTIC DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-5726
Practice Address - Country:US
Practice Address - Phone:336-856-0671
Practice Address - Fax:336-856-0671
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAITH HOME, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-29
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL041732322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children