Provider Demographics
NPI:1427182211
Name:YOUTH ADULT CARE MANAGEMENT
Entity Type:Organization
Organization Name:YOUTH ADULT CARE MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHON
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-933-3505
Mailing Address - Street 1:PO BOX 1013
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28026-1013
Mailing Address - Country:US
Mailing Address - Phone:704-933-3505
Mailing Address - Fax:
Practice Address - Street 1:1395 MISTLETOE RIDGE PL NW
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-7877
Practice Address - Country:US
Practice Address - Phone:704-933-3505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-013-068322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603115Medicaid
NC015WCOtherBCBS