Healthcare Provider Details

I. General information

NPI: 1164407052
Provider Name (Legal Business Name): PRESBYTERIAN HEALTHCARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 08/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 ELLIOTT BARKER LANE
ANGEL FIRE NM
87710
US

IV. Provider business mailing address

PO BOX 26666 PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-337-3301
  • Fax: 505-337-3991
Mailing address:
  • Phone: 505-923-5356
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number2005510
License Number StateNM

VIII. Authorized Official

Name: MR. ROBERT GARCIA
Title or Position: VP REGIONAL OPERATIONS
Credential:
Phone: 505-923-5339