1679716419 NPI number — PUEBLO OF ACOMA

Table of content: (NPI 1679716419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679716419 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:
Provider Other Organization Name Type Code:
6
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:
1679716419
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 641880
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMAHA
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68164-7880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-991-7866
Provider Business Mailing Address Fax Number:
505-552-9470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
74 PINSBAARI DR
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:
87034-1001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-552-7500
Provider Business Practice Location Address Fax Number:
505-552-9470
Provider Enumeration Date:
04/09/2009

Additional Information

Authorized Official

Authorized Official Last Name:
VAUGHN
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
AGENT
Authorized Official Telephone Number:
402-991-7866

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  54980 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 54980 . This is a "NM PRC" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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