Healthcare Provider Details

I. General information

NPI: 1134452105
Provider Name (Legal Business Name): DAVID BURCIAGA YOUTH CARE-BONEM HM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 03/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 W. FIR
PORTALES NM
88101
US

IV. Provider business mailing address

1100 W. 21ST
CLOVIS NM
88101
US

V. Phone/Fax

Practice location:
  • Phone: 575-356-5112
  • Fax: 505-820-9220
Mailing address:
  • Phone: 575-769-2345
  • Fax: 575-769-9013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: