Provider Demographics
NPI:1417149311
Name:BRIDGEBUILDERS FAMILY & YOUTH SERVICES INC.
Entity Type:Organization
Organization Name:BRIDGEBUILDERS FAMILY & YOUTH SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:TYRONNE
Authorized Official - Last Name:GRIER
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:704-864-4623
Mailing Address - Street 1:PO BOX 3707
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-0020
Mailing Address - Country:US
Mailing Address - Phone:704-864-4623
Mailing Address - Fax:704-864-3331
Practice Address - Street 1:1219 CAMBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-1528
Practice Address - Country:US
Practice Address - Phone:704-864-4623
Practice Address - Fax:704-864-3331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHS-036-219320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604145Medicaid