=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528305604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALTERNATIVE YOUTH CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2013
-----------------------------------------------------
Last Update Date | 01/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4880 US HIGHWAY 93 S
-----------------------------------------------------
City | KALISPELL
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59901-7985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-857-2506
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4880 US HIGHWAY 93 S
-----------------------------------------------------
City | KALISPELL
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59901-7985
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE ASSISTANT
-----------------------------------------------------
Name | SHELLEY BROWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 406-857-2506
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3245S0500X
-----------------------------------------------------
Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 08R21
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3245S0500X
-----------------------------------------------------
Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 2624
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------