1679614598 NPI number — INDIAN HEALTH SERVICE

Table of content: (NPI 1679614598)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679614598 NPI number — INDIAN HEALTH SERVICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIAN HEALTH SERVICE
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:
PUEBLO OF SANDIA HEALTH & SOCIAL SVCS
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:
1679614598
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:
5805 RIO LAMA RD NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIO RANCHO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87144-6014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-994-4478
Provider Business Mailing Address Fax Number:
505-771-5107

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
481 SANDIA LOOP
Provider Second Line Business Practice Location Address:
PUEBLO OF SANDIA
Provider Business Practice Location Address City Name:
BERNALILLO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87004-7076
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-771-5116
Provider Business Practice Location Address Fax Number:
505-771-5107
Provider Enumeration Date:
02/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BENFORD-WOSKOFF
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
505-771-5116

Provider Taxonomy Codes

  • Taxonomy code: 261QP0904X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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