Basic Information
| Provider Information | |||||||||
| NPI: | 1639203326 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YOUTH ADULT CARE MANAGEMENT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1013 | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280261013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049333505 | ||||||||
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| Practice Location | |||||||||
| Address1: | 491 LIBERTY DRIVE | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280256318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049333505 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 08/01/2007 | ||||||||
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| AuthorizedOfficialLastName: | BLACK | ||||||||
| AuthorizedOfficialFirstName: | CHON | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7049333505 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | MHL-013-080 | NC | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 6603206 | 05 | NC | MEDICAID | 015WC | 01 | NC | BCBS | OTHER |