Provider Demographics
NPI:1235291923
Name:VISION YOUTH GROUP HOME,INC.
Entity Type:Organization
Organization Name:VISION YOUTH GROUP HOME,INC.
Other - Org Name:NORTHWEST PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUESS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW,LCSW
Authorized Official - Phone:336-508-2203
Mailing Address - Street 1:6107 BASCOM DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27358-9119
Mailing Address - Country:US
Mailing Address - Phone:336-508-2203
Mailing Address - Fax:
Practice Address - Street 1:3415 COTTAGE PL
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-2019
Practice Address - Country:US
Practice Address - Phone:336-288-7685
Practice Address - Fax:336-644-9254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-147322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603097Medicaid