Provider Demographics
NPI:1912141219
Name:WORD OF LIFE OURTREACH OF CAPE FEAR, INC.
Entity Type:Organization
Organization Name:WORD OF LIFE OURTREACH OF CAPE FEAR, INC.
Other - Org Name:ATLAS AT TRINITY
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:910-371-5300
Mailing Address - Street 1:PO BOX 717
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-0717
Mailing Address - Country:US
Mailing Address - Phone:910-371-5300
Mailing Address - Fax:910-371-5302
Practice Address - Street 1:10241 BLACKWELL RD SE
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-8515
Practice Address - Country:US
Practice Address - Phone:910-371-5300
Practice Address - Fax:910-371-5302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-30
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 010-061251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8302371RMedicaid
NC8301346GMedicaid
NC8302371SMedicaid