Provider Demographics
NPI:1881968378
Name:FAITH HOMES & HABILITATION, LLC II
Entity type:Organization
Organization Name:FAITH HOMES & HABILITATION, LLC II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-961-1757
Mailing Address - Street 1:5316 CUMBERLAND PLAIN DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-6367
Mailing Address - Country:US
Mailing Address - Phone:919-758-8375
Mailing Address - Fax:919-400-4277
Practice Address - Street 1:830 N MANGUM ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-2259
Practice Address - Country:US
Practice Address - Phone:919-961-1757
Practice Address - Fax:919-400-4277
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAITH HOMES & HABILITATION, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-29
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-032-117320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1134443252Medicaid