Provider Demographics
NPI:1891874343
Name:PRESBYTERIAN MEDICAL SERVICES
Entity Type:Organization
Organization Name:PRESBYTERIAN MEDICAL SERVICES
Other - Org Name:LOVING HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-982-5565
Mailing Address - Street 1:PO BOX 2267
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87504-2267
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:602 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LOVING
Practice Address - State:NM
Practice Address - Zip Code:88256-0491
Practice Address - Country:US
Practice Address - Phone:575-745-3573
Practice Address - Fax:575-745-3550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6317261QF0400X
NMCL00007330332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
3209651OtherOTHER ID NUMBER
NM50361Medicaid
3209651OtherOTHER ID NUMBER