Provider Demographics
NPI:1912314972
Name:YOUTHBRIDGE
Entity type:Organization
Organization Name:YOUTHBRIDGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HUMAN RESOURCES
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-575-9471
Mailing Address - Street 1:2153 E JOYCE BLVD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4714
Mailing Address - Country:US
Mailing Address - Phone:479-575-9471
Mailing Address - Fax:
Practice Address - Street 1:2153 E JOYCE BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:479-575-9471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171MOOOOOX320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR=========Medicare PIN