Provider Demographics
NPI:1285087452
Name:YOUR MISSING PIECE PSR
Entity type:Organization
Organization Name:YOUR MISSING PIECE PSR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:RIOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-600-3981
Mailing Address - Street 1:222 LA VETA DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1615
Mailing Address - Country:US
Mailing Address - Phone:505-600-3981
Mailing Address - Fax:184-478-4864
Practice Address - Street 1:222 LA VETA DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-1615
Practice Address - Country:US
Practice Address - Phone:505-600-3981
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1T3556251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health