Provider Demographics
NPI:1275656373
Name:YOUTH ENHANCEMENT ALTERNATIVE HOMES, LLC
Entity Type:Organization
Organization Name:YOUTH ENHANCEMENT ALTERNATIVE HOMES, LLC
Other - Org Name:YOUTH ENHANCEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AUNDREY
Authorized Official - Middle Name:C
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:BS,QDDP
Authorized Official - Phone:910-815-2667
Mailing Address - Street 1:PO BOX 2042
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28402-2042
Mailing Address - Country:US
Mailing Address - Phone:910-815-2667
Mailing Address - Fax:910-815-2668
Practice Address - Street 1:2169 HARRISON ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401
Practice Address - Country:US
Practice Address - Phone:910-815-2667
Practice Address - Fax:910-815-2668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408747Medicaid