Healthcare Provider Details

I. General information

NPI: 1124353487
Provider Name (Legal Business Name): YOUTH SHELTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 10/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5686 AGUA FRIA ST
SANTA FE NM
87507-9001
US

IV. Provider business mailing address

PO BOX 28279
SANTA FE NM
87592-8279
US

V. Phone/Fax

Practice location:
  • Phone: 505-983-0586
  • Fax: 505-424-0949
Mailing address:
  • Phone: 505-983-0586
  • Fax: 505-424-0949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE TRUJILLO
Title or Position: RESIDENT ASSISTANT
Credential:
Phone: 505-983-0586