NPIMap

Organization Active NPI

Excalibur Youth Services, LLC.

Doing business as Azalea Way

  • Mental Illness Community Based Residential Treatment Facility
  • Hendersonville, NC
National Provider Identifier
1073032470
Registry record updated Sep 18, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Illness Community Based Residential Treatment FacilityTaxonomy code 320800000X
License
MHL045-119 Issued in NC
Legal business name
EXCALIBUR YOUTH SERVICES, LLC.
Doing business as
Azalea Way
Practice address
145 Azalea Way
Hendersonville, NC 28792-2409
Phone
(864) 836-7220
Fax
(864) 294-1774
NPI assigned
Sep 18, 2017
Last updated
Sep 18, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 18, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Marvin John Short III, JD
Title
Member
Phone
(864) 313-6967

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Illness Community Based Residential Treatment Facility 320800000X MHL045-119 NC Primary

Addresses

Primary practice location

145 Azalea Way
Hendersonville, NC 28792-2409

Mailing address

PO Box 968
Travelers Rest, SC 29690-0968
Phone (864) 836-7220

Other names 1

  • Azalea Way Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Excalibur Youth Services LLC4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1505692800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1505692800000",
    "number": "1073032470",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 968",
            "city": "TRAVELERS REST",
            "state": "SC",
            "postal_code": "296900968",
            "telephone_number": "864-836-7220",
            "fax_number": "864-294-1774"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "145 AZALEA WAY",
            "city": "HENDERSONVILLE",
            "state": "NC",
            "postal_code": "287922409",
            "telephone_number": "864-836-7220",
            "fax_number": "864-294-1774"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EXCALIBUR YOUTH SERVICES, LLC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-09-18",
        "last_updated": "2017-09-18",
        "status": "A",
        "authorized_official_last_name": "SHORT",
        "authorized_official_first_name": "MARVIN",
        "authorized_official_middle_name": "JOHN",
        "authorized_official_title_or_position": "MEMBER",
        "authorized_official_telephone_number": "864-313-6967",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "III",
        "authorized_official_credential": "JD"
    },
    "taxonomies": [
        {
            "code": "320800000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Mental Illness",
            "state": "NC",
            "license": "MHL045-119",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Azalea Way",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Hendersonville, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 18, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.