Healthcare Provider Details

I. General information

NPI: 1912314972
Provider Name (Legal Business Name): YOUTHBRIDGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2153 E JOYCE BLVD
FAYETTVILLE AR
72703
US

IV. Provider business mailing address

2153 E JOYCE BLVD
FAYETTEVILLE AR
72703-4714
US

V. Phone/Fax

Practice location:
  • Phone: 479-575-9471
  • Fax:
Mailing address:
  • Phone: 479-575-9471
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number171MOOOOOX
License Number StateAR

VIII. Authorized Official

Name: MISS MARILYN HOKE
Title or Position: HUMAN RESOURCES
Credential:
Phone: 479-575-9471