Provider Demographics
NPI:1841544814
Name:PRESBYTERIAN INTEL HEALTH FOR LIFE CENTER
Entity type:Organization
Organization Name:PRESBYTERIAN INTEL HEALTH FOR LIFE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT CDS
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-724-7283
Mailing Address - Street 1:4100 SARA ROAD SE, MSRR5
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124
Mailing Address - Country:US
Mailing Address - Phone:505-253-7900
Mailing Address - Fax:
Practice Address - Street 1:4100 SARA ROAD SE, MSRR5
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124
Practice Address - Country:US
Practice Address - Phone:505-253-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCL00010876261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center