Healthcare Provider Details

I. General information

NPI: 1013293885
Provider Name (Legal Business Name): MIDWAY YOUTH AND FAMILY DEVELOPMENT CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2011
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 YAKIMA RD
DEXTER NM
88230-9757
US

IV. Provider business mailing address

75 YAKIMA RD
DEXTER NM
88230-9757
US

V. Phone/Fax

Practice location:
  • Phone: 575-347-5309
  • Fax: 575-347-5753
Mailing address:
  • Phone: 575-347-5309
  • Fax: 575-347-5753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DANNY SONS
Title or Position: PRESIDENT
Credential:
Phone: 575-347-5309