1235291923 NPI number — VISION YOUTH GROUP HOME,INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235291923 NPI number — VISION YOUTH GROUP HOME,INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VISION YOUTH GROUP HOME,INC.
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:
6
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:
1235291923
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6107 BASCOM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUMMERFIELD
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27358-9119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-508-2203
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3415 COTTAGE PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27455-2019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-288-7685
Provider Business Practice Location Address Fax Number:
336-644-9254
Provider Enumeration Date:
12/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GUESS
Authorized Official First Name:
JIMMY
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
336-508-2203

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X , with the licence number:  MHL-041-147 , 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)

  • Identifier: 6603097 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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