Provider Demographics
NPI:1134452105
Name:BURCIAGA, DAVID (YOUTH CARE-BONEM HM)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:BURCIAGA
Suffix:
Gender:M
Credentials:YOUTH CARE-BONEM HM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W. 21ST
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101
Mailing Address - Country:US
Mailing Address - Phone:575-769-2345
Mailing Address - Fax:575-769-9013
Practice Address - Street 1:1111 W. FIR
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-356-5112
Practice Address - Fax:505-820-9220
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-09
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NML7904Medicaid