=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275904633
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUTH DEVELOPMENT, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2015
-----------------------------------------------------
Last Update Date | 10/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1111 EASTERDAY DR NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87112-5115
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-212-7393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6301 CENTRAL AVE NW
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87105-2036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | CHRIS BACA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-212-7393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------