1053397497 NPI number — PRESBYTERIAN HEALTHCARE SERVICES

Table of content: (NPI 1053397497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053397497 NPI number — PRESBYTERIAN HEALTHCARE SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRESBYTERIAN HEALTHCARE SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CLOVIS SWING BED SNF
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053397497
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 26666
Provider Second Line Business Mailing Address:
PROVIDER ENROLLMENT
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87125-6666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-823-8528
Provider Business Mailing Address Fax Number:
505-823-8555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 W 21ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLOVIS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88101-2011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-469-7577
Provider Business Practice Location Address Fax Number:
505-769-7595
Provider Enumeration Date:
12/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
REIFSTECK
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
SR VP CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
505-841-1392

Provider Taxonomy Codes

  • Taxonomy code: 275N00000X , with the licence number:  59304 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2251701 . This is a "PART B" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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