1710020854 NPI number — SUPPORTED LIVING YOUTH FAMILY & CHILDREN SERVICES

Table of content: (NPI 1710020854)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710020854 NPI number — SUPPORTED LIVING YOUTH FAMILY & CHILDREN SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPPORTED LIVING YOUTH FAMILY & CHILDREN SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710020854
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3398
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28111-3398
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-283-6002
Provider Business Mailing Address Fax Number:
704-225-1582

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 SERENITY HILLS DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28110-8610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-283-6002
Provider Business Practice Location Address Fax Number:
704-225-1582
Provider Enumeration Date:
02/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HILLIAN
Authorized Official First Name:
KIRK
Authorized Official Middle Name:
ANTHONY
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
704-283-6002

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  MHL090120 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com