Provider Demographics
NPI:1568509750
Name:YOUTH ENRICHMENT GROUP HOME, INC.
Entity Type:Organization
Organization Name:YOUTH ENRICHMENT GROUP HOME, INC.
Other - Org Name:LOCHWOOD II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEVOLIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SWEET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-382-6658
Mailing Address - Street 1:4299 HARBOR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-8576
Mailing Address - Country:US
Mailing Address - Phone:336-382-6658
Mailing Address - Fax:
Practice Address - Street 1:1807 LOCHWOOD DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-8574
Practice Address - Country:US
Practice Address - Phone:336-382-6658
Practice Address - Fax:187-784-6896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320800000X
NCMHL-041-785322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603979Medicaid