Provider Demographics
NPI:1356670178
Name:UPSIDE TO YOUTH DEVELOPMENT, LLC
Entity Type:Organization
Organization Name:UPSIDE TO YOUTH DEVELOPMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:GAY
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:804-541-7894
Mailing Address - Street 1:943 STARLING AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-6405
Mailing Address - Country:US
Mailing Address - Phone:804-590-4453
Mailing Address - Fax:
Practice Address - Street 1:943 STARLING AVE
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-6405
Practice Address - Country:US
Practice Address - Phone:804-590-4453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1082-05-001253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care