1801840905 NPI number — MOUNTAIN YOUTH RESOURCES, INC.

Table of content: (NPI 1801840905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801840905 NPI number — MOUNTAIN YOUTH RESOURCES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN YOUTH RESOURCES, 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:
1801840905
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 99
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEBSTER
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28788-0099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-586-8958
Provider Business Mailing Address Fax Number:
828-586-0649

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
151 DESOTO TRAIL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYLVA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-586-8958
Provider Business Practice Location Address Fax Number:
828-586-0649
Provider Enumeration Date:
05/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KIRKLAND
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATIVE ASSISTANT
Authorized Official Telephone Number:
828-586-8958

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8300610B , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8301101 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8301101Q , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300610G , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300610H , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 017P2 . This is a "BCBSNC PROVIDER NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 6005341 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8300610 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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