Basic Information
| Provider Information | |||||||||
| NPI: | 1972887990 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRESBYTERIAN MEDICAL SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PMS-LAKE ARTHUR SCHOOL-BASED HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2267 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875042267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059825565 | ||||||||
| FaxNumber: | 5059924990 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LAKE ARTHUR | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5757469848 | ||||||||
| FaxNumber: | 5757469840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2011 | ||||||||
| LastUpdateDate: | 01/06/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | ROBERTA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5059825565 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PRESBYTERIAN MEDICAL SERVICES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
ID Information
| ID | Type | State | Issuer | Description | 00000 | 05 | NM | MEDICAID |