Healthcare Provider Details

I. General information

NPI: 1952549875
Provider Name (Legal Business Name): YOUTH ODYSSEY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 01/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 WHITE MOUNTAIN MEADOWS DR
RUIDOSO NM
88345-5816
US

IV. Provider business mailing address

PO BOX 1065
RUIDOSO NM
88355-1065
US

V. Phone/Fax

Practice location:
  • Phone: 877-834-4430
  • Fax: 575-258-3907
Mailing address:
  • Phone: 877-834-4430
  • Fax: 575-258-3907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number4737
License Number StateNM

VIII. Authorized Official

Name: JON ROBERT WORBETS
Title or Position: EXECUTIVE DIRECTOR
Credential: LPCC
Phone: 877-834-4430