Healthcare Provider Details

I. General information

NPI: 1720109358
Provider Name (Legal Business Name): PEDIATRIC HEALTH SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 03/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10110 SPAIN RD NE
ALBUQUERQUE NM
87111-1965
US

IV. Provider business mailing address

10110 SPAIN RD NE
ALBUQUERQUE NM
87111-1965
US

V. Phone/Fax

Practice location:
  • Phone: 505-294-5065
  • Fax: 505-298-2731
Mailing address:
  • Phone: 505-294-5065
  • Fax: 505-298-2731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA-569-71
License Number StateNM

VIII. Authorized Official

Name: LESLIE SUMNER
Title or Position: VP
Credential:
Phone: 505-294-5065