=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619123189
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRIAD CENTERS FOR YOUTH, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2008
-----------------------------------------------------
Last Update Date | 08/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 GLENDALE OAKS CT
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27406-8221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-456-7705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 GLENDALE OAKS CT
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27406-8221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-456-7705
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. GAYLAND ANTHONY OLIVER
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 336-456-7705
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | 041871
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------