Provider Demographics
NPI:1558301903
Name:PRIMARY CARE AND PREVENTIVE SERVICES, PC
Entity Type:Organization
Organization Name:PRIMARY CARE AND PREVENTIVE SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-883-1259
Mailing Address - Street 1:4710 JEFFERSON ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-2155
Mailing Address - Country:US
Mailing Address - Phone:505-883-1259
Mailing Address - Fax:505-883-3020
Practice Address - Street 1:4710 JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2155
Practice Address - Country:US
Practice Address - Phone:505-883-1259
Practice Address - Fax:505-883-3020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM86-185207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM202006617OtherPRESBYTERIAN PIN
NM975291OtherUNITED HEALTHCARE PIN
NM202006617OtherPRESBYTERIAN PIN