=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386206274
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUTH HOMES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2019
-----------------------------------------------------
Last Update Date | 07/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1159 EVERETT CT
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94518-1714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-933-2627
-----------------------------------------------------
Fax | 925-933-5824
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3480 BUSKIRK AVE STE 210
-----------------------------------------------------
City | PLEASANT HILL
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94523-4304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-933-2627
-----------------------------------------------------
Fax | 925-933-5824
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | SHAINA VAN PELT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-876-1153
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------