Provider Demographics
NPI:1669529178
Name:FREE WILL BAPTIST CHILDRENS HOME, INC.
Entity type:Organization
Organization Name:FREE WILL BAPTIST CHILDRENS HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-235-2161
Mailing Address - Street 1:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:MIDDLESEX
Mailing Address - State:NC
Mailing Address - Zip Code:27557-0249
Mailing Address - Country:US
Mailing Address - Phone:252-235-2161
Mailing Address - Fax:252-235-2625
Practice Address - Street 1:7907 BUCK DEANS ROAD
Practice Address - Street 2:
Practice Address - City:MIDDLESEX
Practice Address - State:NC
Practice Address - Zip Code:27557
Practice Address - Country:US
Practice Address - Phone:252-235-2161
Practice Address - Fax:252-235-2625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCB003581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005069Medicaid