1265511299 NPI number — PUEBLO OF SAN FELIPE

Table of content: (NPI 1265511299)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265511299 NPI number — PUEBLO OF SAN FELIPE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUEBLO OF SAN FELIPE
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:
SAN FELIPE PUEBLO HEALTH & WELLNESS DEPARTMENT
Provider Other Organization Name Type Code:
5
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:
1265511299
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4339
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN FELIPE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-867-9616
Provider Business Mailing Address Fax Number:
505-771-9992

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 CEDAR RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN FELIPE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-867-9616
Provider Business Practice Location Address Fax Number:
505-771-9992
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GARCIA
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
PUEBLO OF SAN FELIPE TRIBAL ADMIN
Authorized Official Telephone Number:
505-867-3381

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 99624371 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 81271875 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 81271875 . This is a "PHARMACY" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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