Basic Information
| Provider Information | |||||||||
| NPI: | 1063573509 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SANDIA HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 VASSAR DR NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052487711 | ||||||||
| FaxNumber: | 5052487701 | ||||||||
| Practice Location | |||||||||
| Address1: | 481 SANDIA LOOP | ||||||||
| Address2: | |||||||||
| City: | BERNALILLO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870047076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058674487 | ||||||||
| FaxNumber: | 5057715126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 04/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | RICKERT | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5052484062 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALBUQUERQUE INDIAN HEALTH CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
| ID | Type | State | Issuer | Description | HSZ164 | 01 | NM | GROUP | OTHER | H7890 | 05 | NM | MEDICAID |