Provider Demographics
NPI:1508914896
Name:STATE OF NEW MEXICO
Entity Type:Organization
Organization Name:STATE OF NEW MEXICO
Other - Org Name:CHILDREN'S MEDICAL SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTIANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:505-476-8851
Mailing Address - Street 1:2040 S PACHECO ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5472
Mailing Address - Country:US
Mailing Address - Phone:505-476-8868
Mailing Address - Fax:505-476-8896
Practice Address - Street 1:2040 S PACHECO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5472
Practice Address - Country:US
Practice Address - Phone:505-476-8868
Practice Address - Fax:505-476-8896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM64372766Medicaid
NM00049023Medicaid