1184787400 NPI number — BERNALILLO COUNTY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184787400 NPI number — BERNALILLO COUNTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BERNALILLO COUNTY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CHILDREN'S COMMUNITY MENTAL HEALTH CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184787400
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6506
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87197-6506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-342-3740
Provider Business Mailing Address Fax Number:
505-342-3785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5100 2ND ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87107-4009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-342-3799
Provider Business Practice Location Address Fax Number:
505-342-3785
Provider Enumeration Date:
12/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SWISSTACK
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
505-342-3740

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  3079 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 251S00000X , with the licence number: 3079 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 88928551 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: NM600050 . This is a "VALUE OPTIONS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 17367 . This is a "LOVELACE COMMERCIAL" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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