Provider Demographics
NPI:1720109358
Name:PEDIATRIC HEALTH SERVICES PC
Entity Type:Organization
Organization Name:PEDIATRIC HEALTH SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-294-5065
Mailing Address - Street 1:10110 SPAIN RD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-1965
Mailing Address - Country:US
Mailing Address - Phone:505-294-5065
Mailing Address - Fax:505-298-2731
Practice Address - Street 1:10110 SPAIN RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-1965
Practice Address - Country:US
Practice Address - Phone:505-294-5065
Practice Address - Fax:505-298-2731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-569-712080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty