MEDICARE: YOUTH ENRICHMENT GROUP HOME, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	MHL-041-658	NC
2	320800000X	Mental Illness Community Based Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528119096
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YOUTH ENRICHMENT GROUP HOME, INC.

Provider Business Mailing Address
First Line	:	4299 HARBOR RIDGE DR
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27406-8576
Country	:	US
Telephone Number	:	336-382-6658
Fax Number	:	877-846-8962

Provider Business Practice Location Address
First Line	:	203 HAMMOND DR
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27406-8149
Country	:	US
Telephone Number	:	336-389-1913
Fax Number	:	877-846-8962

Authorized Official
Title or Position	:	ASSISTANT DIRECTOR
Name	:	MRS. DEVOLIA PRATT SWEET
Credential	:
Telephone Number	:	336-382-6658

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	06/04/2019

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