Basic Information
Provider Information
NPI: 1114373883
EntityType: 2
ReplacementNPI:  
OrganizationName: TRINITY YOUTH SERVICES
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: TRINITY APPLE VALLEY
OtherOrganizationType: 5
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 10755 APPLE VALLEY RD
Address2:  
City: APPLE VALLEY
State: CA
PostalCode: 923083684
CountryCode: US
TelephoneNumber: 7602479840
FaxNumber: 7602479810
Practice Location
Address1: 10755 APPLE VALLEY RD
Address2:  
City: APPLE VALLEY
State: CA
PostalCode: 923083684
CountryCode: US
TelephoneNumber: 7602479840
FaxNumber: 7602479810
Other Information
ProviderEnumerationDate: 05/11/2016
LastUpdateDate: 10/15/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: ADAMS
AuthorizedOfficialFirstName: JAMES
AuthorizedOfficialMiddleName: R.
AuthorizedOfficialTitleorPosition: DIRECTOR
AuthorizedOfficialTelephone: 6264440539
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix: IV
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QM0855X CAN Ambulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
322D00000X  Y Residential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children 

No ID Information.


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