1619193299 NPI number — THE YOUTH SUCCESS NETWORK LLC

Table of content: (NPI 1619193299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619193299 NPI number — THE YOUTH SUCCESS NETWORK LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE YOUTH SUCCESS NETWORK 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:
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:
1619193299
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
375 SYLVAN AVE
Provider Second Line Business Mailing Address:
SUITE 30
Provider Business Mailing Address City Name:
ENGLEWOOD CLIFFS
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07632-2725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-731-3739
Provider Business Mailing Address Fax Number:
201-732-3582

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
375 SYLVAN AVE
Provider Second Line Business Practice Location Address:
SUITE 30
Provider Business Practice Location Address City Name:
ENGLEWOOD CLIFFS
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07632-2725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-731-3739
Provider Business Practice Location Address Fax Number:
201-731-3582
Provider Enumeration Date:
04/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ISHIBASHI
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
SETSUO
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
551-574-8739

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  64669006 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0030872 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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