Provider Demographics
NPI:1073032470
Name:EXCALIBUR YOUTH SERVICES, LLC.
Entity Type:Organization
Organization Name:EXCALIBUR YOUTH SERVICES, LLC.
Other - Org Name:AZALEA WAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:III
Authorized Official - Credentials:JD
Authorized Official - Phone:864-313-6967
Mailing Address - Street 1:PO BOX 968
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-0968
Mailing Address - Country:US
Mailing Address - Phone:864-836-7220
Mailing Address - Fax:864-294-1774
Practice Address - Street 1:145 AZALEA WAY
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28792-2409
Practice Address - Country:US
Practice Address - Phone:864-836-7220
Practice Address - Fax:864-294-1774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-18
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL045-119320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness