Healthcare Provider Details

I. General information

NPI: 1669042073
Provider Name (Legal Business Name): YOSIAH DAVILA BT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 W 2ND ST
ROSWELL NM
88201-2013
US

IV. Provider business mailing address

1350 HILLRISE CIR
LAS CRUCES NM
88011-4759
US

V. Phone/Fax

Practice location:
  • Phone: 575-623-2615
  • Fax: 575-622-6703
Mailing address:
  • Phone: 575-522-9500
  • Fax: 575-523-1108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: