1477676567 NPI number — PUEBLO OF JEMEZ

Table of content: (NPI 1477676567)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477676567 NPI number — PUEBLO OF JEMEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PUEBLO OF JEMEZ
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:
JEMEZ HEALTH CENTER PHARMACY
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:
1477676567
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 279
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEMEZ PUEBLO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87024-0279
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-831-0130
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 SHEEPSPRINGS WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEMEZ PUEBLO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-834-0130
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROSALES
Authorized Official First Name:
NOHEMY
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS OFFICE MANAGER
Authorized Official Telephone Number:
575-834-3187

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)





Copyright © 2007-2024 www.npivalidator.com