Provider Demographics
NPI:1336125764
Name:PRESBYTERIAN HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:PRESBYTERIAN HEALTHCARE SERVICES
Other - Org Name:SOCORRO GENERAL HOSPITAL HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARMIGNANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-923-5356
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 1:1202 HIGHWAY 60 BLDG E
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-3914
Practice Address - Country:US
Practice Address - Phone:575-835-8343
Practice Address - Fax:575-835-3986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-19
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X, 207R00000X
NM6052251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251G00000XAgenciesHospice Care, Community Based
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM321532Medicare ID - Type Unspecified