Provider Demographics
NPI:1538319421
Name:YOUTH OPPORTUNITY CENTER
Entity Type:Organization
Organization Name:YOUTH OPPORTUNITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROWRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-289-5437
Mailing Address - Street 1:3700 W KILGORE AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-4810
Mailing Address - Country:US
Mailing Address - Phone:765-289-5437
Mailing Address - Fax:765-213-5094
Practice Address - Street 1:3700 W KILGORE AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-4810
Practice Address - Country:US
Practice Address - Phone:765-289-5437
Practice Address - Fax:765-213-5094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042115A103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200888010Medicaid