Provider Demographics
NPI:1740592054
Name:BERNALILLO COUNTY YOUTH SERVICES CENTER
Entity Type:Organization
Organization Name:BERNALILLO COUNTY YOUTH SERVICES CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:SWISSTACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-7122
Mailing Address - Street 1:PO BOX 25945
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-0945
Mailing Address - Country:US
Mailing Address - Phone:505-468-7236
Mailing Address - Fax:505-462-9917
Practice Address - Street 1:5100 2ND ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4009
Practice Address - Country:US
Practice Address - Phone:505-468-7236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-02
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM9628207Q00000X
NM97PA03363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty