Provider Demographics
NPI:1669602348
Name:ROCKY MOUNTAINYOUTH CORPS
Entity type:Organization
Organization Name:ROCKY MOUNTAINYOUTH CORPS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUITVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:TH
Authorized Official - Last Name:COLONIUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-751-1420
Mailing Address - Street 1:PO BOX 1960
Mailing Address - Street 2:1021 SALAZAR ROAD
Mailing Address - City:RANCHOS DE TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87557-1960
Mailing Address - Country:US
Mailing Address - Phone:575-751-1420
Mailing Address - Fax:575-751-1136
Practice Address - Street 1:1021 SALAZAR RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-8212
Practice Address - Country:US
Practice Address - Phone:575-751-1420
Practice Address - Fax:575-751-1136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-16
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health