Provider Demographics
NPI:1780875138
Name:THREE FORKS HOME
Entity type:Organization
Organization Name:THREE FORKS HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:C.
Authorized Official - Middle Name:F
Authorized Official - Last Name:MCDOWELL
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:336-474-1260
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:BAPTIST CHILDREN'S HOMES OF NC, INC
Mailing Address - City:THOMASVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27361-0338
Mailing Address - Country:US
Mailing Address - Phone:336-474-1260
Mailing Address - Fax:
Practice Address - Street 1:392 CAMP JOY ROAD
Practice Address - Street 2:THREE FORKS HOME
Practice Address - City:ZIONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28698-9759
Practice Address - Country:US
Practice Address - Phone:828-350-1254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 095 043320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMHL 095-043OtherSTATE LICENSE NUMBER