Healthcare Provider Details

I. General information

NPI: 1780791293
Provider Name (Legal Business Name): PRESBYTERIAN MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S DIAMOND AVE
DEMING NM
88030-3752
US

IV. Provider business mailing address

PO BOX 2267
SANTA FE NM
87504-2267
US

V. Phone/Fax

Practice location:
  • Phone: 575-546-4663
  • Fax: 575-546-4844
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberCL00010267
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number3126
License Number StateNM

VIII. Authorized Official

Name: ROBERTA LEE
Title or Position: VP OF FINANCE
Credential:
Phone: 505-982-5565