Healthcare Provider Details

I. General information

NPI: 1427124601
Provider Name (Legal Business Name): PRESBYTERIAN MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 07/21/2022
Certification Date: 01/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 CENTRAL AVE
TULAROSA NM
88352-2063
US

IV. Provider business mailing address

PO BOX 2267
SANTA FE NM
87504-2267
US

V. Phone/Fax

Practice location:
  • Phone: 505-585-1250
  • Fax: 505-585-1251
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberCL00008239
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNM

VIII. Authorized Official

Name: DOUG SMITH
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 505-982-5565