Healthcare Provider Details

I. General information

NPI: 1699849794
Provider Name (Legal Business Name): CYFD-STATE OF NEW MEXICO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3409 PAN AMERICAN FWY NE 3409 PAN AMERICAN FRWY
ALBUQUERQUE NM
87107-4786
US

IV. Provider business mailing address

300 SAN MATEO BLVD NE STE 410 300 SAN MATEO BLVD NE STE 410
ALBUQUERQUE NM
87108-1503
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-6372
  • Fax: 505-841-2949
Mailing address:
  • Phone: 505-841-6372
  • Fax: 505-841-2949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. MINOR MORGAN
Title or Position: BUREAU CHIEF, CYFDJJS ENTITLEMENT
Credential: LISW
Phone: 505-841-6372