Provider Demographics
NPI:1538144415
Name:PRESBYTERIAN HEALTHCARE SERVICES
Entity Type:Organization
Organization Name:PRESBYTERIAN HEALTHCARE SERVICES
Other - Org Name:CORONA HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP REGIONAL DELIVERY SYSTEM
Authorized Official - Prefix:MR
Authorized Official - First Name:BO
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-835-8341
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 1:471 MAIN STREET
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NM
Practice Address - Zip Code:88318
Practice Address - Country:US
Practice Address - Phone:505-849-1561
Practice Address - Fax:505-354-0056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3156261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM=========COtherPART B
NM323855Medicare Oscar/Certification