Healthcare Provider Details

I. General information

NPI: 1144843491
Provider Name (Legal Business Name): PRESBYTERIAN HEALTHCARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2020
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 SUDDERTH DR
RUIDOSO NM
88345-6002
US

IV. Provider business mailing address

PRESBYTERIAN PROVIDER ENROLLMENT PO BOX 26666
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 575-257-8200
  • Fax: 575-630-4237
Mailing address:
  • Phone: 505-923-5356
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY T POLAND
Title or Position: MANAGER, PROVIDER ENROLLMENT
Credential:
Phone: 505-923-5355