Healthcare Provider Details

I. General information

NPI: 1447632617
Provider Name (Legal Business Name): PRESBYTERIAN HEALTHCARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL AVE SE
ALBUQUERQUE NM
87106-4930
US

IV. Provider business mailing address

PO BOX 26666 PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-1234
  • Fax:
Mailing address:
  • Phone: 505-823-8528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License NumberCNP-02691
License Number StateNM

VIII. Authorized Official

Name: MR. MARK PHILLIP JOHNSTON
Title or Position: NURSE PRACTITIONER/ER
Credential: NP
Phone: 505-823-8528