1710343942 NPI number — PUEBLO OF ACOMA

Table of content: (NPI 1710343942)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710343942 NPI number — PUEBLO OF ACOMA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUEBLO OF ACOMA
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:
ACOMA BEHAVIORAL HEALTH SERVICES
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:
1710343942
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 328
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ACOMA
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87034-0328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-552-6661
Provider Business Mailing Address Fax Number:
505-552-6426

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 PINSBAARI DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ACOMA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87034-0328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-552-6661
Provider Business Practice Location Address Fax Number:
505-552-6426
Provider Enumeration Date:
01/04/2016

Additional Information

Authorized Official

Authorized Official Last Name:
PAHOS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
LEAD CLINICIAN, BHS
Authorized Official Telephone Number:
505-552-6661

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 252Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 347C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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