Provider Demographics
NPI:1326195769
Name:PMS DBA ROUNDTREE CHILDRENS' DEVELOPMENT SERVICES
Entity Type:Organization
Organization Name:PMS DBA ROUNDTREE CHILDRENS' DEVELOPMENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUG
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-982-5565
Mailing Address - Street 1:608 REILLY AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499
Mailing Address - Country:US
Mailing Address - Phone:505-327-7720
Mailing Address - Fax:505-992-4990
Practice Address - Street 1:608 REILLY AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2634
Practice Address - Country:US
Practice Address - Phone:505-443-4303
Practice Address - Fax:505-443-8311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME7132Medicaid