Healthcare Provider Details

I. General information

NPI: 1669535837
Provider Name (Legal Business Name): CHIMAYO YOUTH CONSERVATION CORPS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CR103, MANZANA CENTER-BUILDING 3
CHIMAYO NM
87522-1027
US

IV. Provider business mailing address

PO BOX 1027
CHIMAYO NM
87522-1027
US

V. Phone/Fax

Practice location:
  • Phone: 505-351-1456
  • Fax: 505-351-1556
Mailing address:
  • Phone: 505-351-1456
  • Fax: 505-351-1556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. SUELLEN STRALE
Title or Position: EXECUTIVE DIRECTOR
Credential: MA
Phone: 505-351-1456