Provider Demographics
NPI:1932215886
Name:J. L. REDFORD, INC.
Entity type:Organization
Organization Name:J. L. REDFORD, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:MASTER'S DEGREE
Authorized Official - Phone:336-972-0531
Mailing Address - Street 1:1922 MARTIN LUTHER KING, JR. DRIVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-1361
Mailing Address - Country:US
Mailing Address - Phone:336-972-0531
Mailing Address - Fax:336-720-9521
Practice Address - Street 1:1922 MARTIN LUTHER KING, JR. DRIVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-1361
Practice Address - Country:US
Practice Address - Phone:336-972-0053
Practice Address - Fax:336-720-9521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4537320900000X
NC320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3409110Medicaid