Provider Demographics
NPI:1831256858
Name:DWAYNE'S EXTENDED FAMILY SERVICES, INC.
Entity type:Organization
Organization Name:DWAYNE'S EXTENDED FAMILY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-638-3494
Mailing Address - Street 1:1215 BALES CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282-9149
Mailing Address - Country:US
Mailing Address - Phone:336-638-3494
Mailing Address - Fax:336-638-3494
Practice Address - Street 1:1421 WALNUT ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6648
Practice Address - Country:US
Practice Address - Phone:336-638-3494
Practice Address - Fax:336-638-3494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-676322D00000X
NCMHL-041-627322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children