Healthcare Provider Details

I. General information

NPI: 1760026942
Provider Name (Legal Business Name): YOUTH HEALTH ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2019
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 HOB RD
LOS LUNAS NM
87031-7601
US

IV. Provider business mailing address

299 N 200 W
BOUNTIFUL UT
84010-7043
US

V. Phone/Fax

Practice location:
  • Phone: 505-903-4411
  • Fax: 801-683-8962
Mailing address:
  • Phone: 801-330-8845
  • Fax: 801-683-8962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: SHAYNE MILLER
Title or Position: CFO
Credential:
Phone: 801-330-8845