Healthcare Provider Details

I. General information

NPI: 1639883564
Provider Name (Legal Business Name): BUFFALO'S CONCERNED FOR YOUTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2023
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 FOXMEADE CT
SALISBURY NC
28144-8837
US

IV. Provider business mailing address

1317 FORESTDALE DR
SALISBURY NC
28144-2128
US

V. Phone/Fax

Practice location:
  • Phone: 704-870-9584
  • Fax:
Mailing address:
  • Phone: 980-330-3054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIE A CORNELIUS
Title or Position: OWNER
Credential:
Phone: 704-870-9584