1073167847 NPI number — YOUTH VILLAGES, INC

Table of content: (NPI 1073167847)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073167847 NPI number — YOUTH VILLAGES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
YOUTH VILLAGES, 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:
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:
1073167847
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3320 BROTHER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEMPHIS
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38133-8950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-251-5000
Provider Business Mailing Address Fax Number:
901-251-5001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4685 DORSETT SHOALS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30135-4921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-251-5000
Provider Business Practice Location Address Fax Number:
901-251-5001
Provider Enumeration Date:
07/30/2019

Additional Information

Authorized Official

Authorized Official Last Name:
LAWLER
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
901-251-5000

Provider Taxonomy Codes

  • Taxonomy code: 323P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 330507828C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 108150400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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