Basic Information
Provider Information | |||||||||
NPI: | 1275699100 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | YOUTH ADULT CARE MANAGEMENT, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1013 | ||||||||
Address2: |   | ||||||||
City: | CONCORD | ||||||||
State: | NC | ||||||||
PostalCode: | 280261013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7049333505 | ||||||||
FaxNumber: | 7049333525 | ||||||||
Practice Location | |||||||||
Address1: | 345 DELLWOOD CT SE | ||||||||
Address2: |   | ||||||||
City: | CONCORD | ||||||||
State: | NC | ||||||||
PostalCode: | 280252720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7049333505 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2006 | ||||||||
LastUpdateDate: | 08/01/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLACK | ||||||||
AuthorizedOfficialFirstName: | HERMAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7049333505 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | MHL-013-093 | NC | Y |   | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |   |
ID Information
ID | Type | State | Issuer | Description | O15WC | 01 | NC | BCBS | OTHER | 6603271 | 05 | NC |   | MEDICAID |