Provider Demographics
NPI:1235114125
Name:PRESBYTERIAN HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:PRESBYTERIAN HEALTHCARE SERVICES
Other - Org Name:CARRIZOZO HEALTH CENTER
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:505-923-5356
Mailing Address - Street 1:710 AVENUE E
Mailing Address - Street 2:
Mailing Address - City:CARRIZOZO
Mailing Address - State:NM
Mailing Address - Zip Code:88301-0008
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:710 AVENUE E
Practice Address - Street 2:
Practice Address - City:CARRIZOZO
Practice Address - State:NM
Practice Address - Zip Code:88301-0008
Practice Address - Country:US
Practice Address - Phone:505-648-2317
Practice Address - Fax:505-648-4113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X, 207R00000X
NM6075261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM47894Medicaid
NM=========COtherPART B
NM323831Medicare Oscar/Certification