Provider Demographics
NPI:1821120742
Name:CHILDREN'S MEDICAL SERVICES
Entity Type:Organization
Organization Name:CHILDREN'S MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:TISA
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERNALLY
Authorized Official - Suffix:
Authorized Official - Credentials:LBSW
Authorized Official - Phone:505-327-7606
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1972933844Medicaid