Provider Demographics
NPI:1982834073
Name:CHAPARRAL YOUTH SERVICES
Entity Type:Organization
Organization Name:CHAPARRAL YOUTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHEREE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-827-1169
Mailing Address - Street 1:56 THREE HUNTS DR
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-8998
Mailing Address - Country:US
Mailing Address - Phone:910-827-1169
Mailing Address - Fax:
Practice Address - Street 1:56 THREE HUNTS DR
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-8998
Practice Address - Country:US
Practice Address - Phone:910-827-1169
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHAPARRAL YOUTH SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-078-170251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601169Medicaid
NC8301829Medicaid
NC8302582Medicaid