Provider Demographics
NPI:1083917884
Name:YOUTH OPPORTUNITIES
Entity Type:Organization
Organization Name:YOUTH OPPORTUNITIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P. FINANCE AND BUSINESS
Authorized Official - Prefix:MR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:MARIANO
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-724-1412
Mailing Address - Street 1:7670 NORTHPOINT CT.
Mailing Address - Street 2:
Mailing Address - City:WISNTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3336
Mailing Address - Country:US
Mailing Address - Phone:336-724-1412
Mailing Address - Fax:336-724-1464
Practice Address - Street 1:810 BAGLEY ROAD
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-9897
Practice Address - Country:US
Practice Address - Phone:336-724-1412
Practice Address - Fax:336-724-1464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251S00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8303449RMedicaid