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General NPI Number Information
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NPI Number | 1740592054
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Entity Type | Organization
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Legal Business Name | BERNALILLO COUNTY YOUTH SERVICES CENTER
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Dates
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Enumeration Date | 07/02/2010
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Last Update Date | 07/02/2010
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Provider Practice Location Address
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Address Line | 5100 2ND ST NW
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City | ALBUQUERQUE
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State | NM
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Zip | 87107-4009
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Country | US
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Telephone | 505-468-7236
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 25945
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City | ALBUQUERQUE
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State | NM
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Zip | 87125-0945
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Country | US
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Telephone | 505-468-7236
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Fax | 505-462-9917
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. THOMAS E. SWISSTACK
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Credential |
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Telephone | 505-468-7122
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 97PA03
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 9628
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License Number State | NM
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