Provider Demographics
NPI:1114233939
Name:FAMILY YOUTH INC
Entity Type:Organization
Organization Name:FAMILY YOUTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BMS PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRECK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:PENROD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-117-4203
Mailing Address - Street 1:2190 MARS AVE
Mailing Address - Street 2:11
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88012-8532
Mailing Address - Country:US
Mailing Address - Phone:505-227-4203
Mailing Address - Fax:
Practice Address - Street 1:1320 S SOLANO DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3758
Practice Address - Country:US
Practice Address - Phone:575-556-1669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management