1982854360 NPI number — INNERCHANGE YOUTH HOMES LLC

Table of content: (NPI 1982854360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982854360 NPI number — INNERCHANGE YOUTH HOMES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNERCHANGE YOUTH HOMES LLC
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:
INNERCHANGE YOUTH DIVISION 1
Provider Other Organization Name Type Code:
3
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:
1982854360
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 36448
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28236-6448
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-884-0096
Provider Business Mailing Address Fax Number:
704-884-0097

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
724 RAINDROPS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GASTONIA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28054-1779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-884-0096
Provider Business Practice Location Address Fax Number:
704-884-0097
Provider Enumeration Date:
09/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SAWYER
Authorized Official First Name:
DINA
Authorized Official Middle Name:
CATRESS
Authorized Official Title or Position:
OWNER/DIRECTOR
Authorized Official Telephone Number:
704-458-1356

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X , with the licence number:  MHL036260 , 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)





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