Provider Demographics
NPI:1164407052
Name:PRESBYTERIAN HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:PRESBYTERIAN HEALTHCARE SERVICES
Other - Org Name:MORENO VALLEY HEALTHCARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP REGIONAL OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-923-5339
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:11 ELLIOTT BARKER LANE
Practice Address - Street 2:
Practice Address - City:ANGEL FIRE
Practice Address - State:NM
Practice Address - Zip Code:87710
Practice Address - Country:US
Practice Address - Phone:505-337-3301
Practice Address - Fax:505-337-3991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2010-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X, 207R00000X
NM2005510261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ7392Medicaid
NM=========NMedicare UPIN