Healthcare Provider Details

I. General information

NPI: 1972670305
Provider Name (Legal Business Name): PRESBYTERIAN MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 N 5TH ST
GALLUP NM
87301-5306
US

IV. Provider business mailing address

PO BOX 2267 RMACY
SANTA FE NM
87504-2267
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-3120
  • Fax: 505-863-2961
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberCL00007461
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNM

VIII. Authorized Official

Name: ROBERTA LEE
Title or Position: CFO
Credential:
Phone: 505-982-5565