Healthcare Provider Details

I. General information

NPI: 1275904633
Provider Name (Legal Business Name): YOUTH DEVELOPMENT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2015
Last Update Date: 10/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 EASTERDAY DR NE
ALBUQUERQUE NM
87112-5115
US

IV. Provider business mailing address

6301 CENTRAL AVE NW
ALBUQUERQUE NM
87105-2036
US

V. Phone/Fax

Practice location:
  • Phone: 505-212-7393
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CHRIS BACA
Title or Position: BILLING MANAGER
Credential:
Phone: 505-212-7393