Basic Information
| Provider Information | |||||||||
| NPI: | 1720208887 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNITED METHODIST YOUTHVILLE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | YOUTHVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 W BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | KS | ||||||||
| PostalCode: | 671142037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162831950 | ||||||||
| FaxNumber: | 3162839540 | ||||||||
| Practice Location | |||||||||
| Address1: | 11200 LARIAT WAY | ||||||||
| Address2: | |||||||||
| City: | DODGE CITY | ||||||||
| State: | KS | ||||||||
| PostalCode: | 678017328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6202250276 | ||||||||
| FaxNumber: | 6202250279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MONARES | ||||||||
| AuthorizedOfficialFirstName: | DANY | ||||||||
| AuthorizedOfficialMiddleName: | RAY | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3162831950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LBSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 566 | KS | Y | Agencies | Community/Behavioral Health |
No ID Information.