Healthcare Provider Details

I. General information

NPI: 1275094567
Provider Name (Legal Business Name): PRESBYTERIAN HEALTHCARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 CHAMA AVE
SANTA FE NM
87505
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 505-988-2211
  • Fax: 505-772-7613
Mailing address:
  • Phone: 505-923-5356
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VIII. Authorized Official

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