Healthcare Provider Details

I. General information

NPI: 1558653758
Provider Name (Legal Business Name): BERNALILLO COUNTY YOUTH SERVICES CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2011
Last Update Date: 05/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 2ND ST NW
ALBUQUERQUE NM
87107-4009
US

IV. Provider business mailing address

5100 2ND ST NW P O BOX 25745
ALBUQUERQUE NM
87107-4009
US

V. Phone/Fax

Practice location:
  • Phone: 505-468-7106
  • Fax: 505-462-9985
Mailing address:
  • Phone: 505-468-7106
  • Fax: 505-462-9985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS E SWISSTACK
Title or Position: DIRECTOR
Credential:
Phone: 505-468-7122