Basic Information
Provider Information | |||||||||
NPI: | 1225103922 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ACOMA-CANONCITO-LAGUNA INDIAN HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ACOMA CANONCITO LAGUNA INDIAN | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 130 | ||||||||
Address2: |   | ||||||||
City: | SAN FIDEL | ||||||||
State: | NM | ||||||||
PostalCode: | 870490130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5055525300 | ||||||||
FaxNumber: | 5055525490 | ||||||||
Practice Location | |||||||||
Address1: | 80 B VETERANS BLVD | ||||||||
Address2: |   | ||||||||
City: | ACOMA | ||||||||
State: | NM | ||||||||
PostalCode: | 87034 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5055525300 | ||||||||
FaxNumber: | 5055525490 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/21/2006 | ||||||||
LastUpdateDate: | 03/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALLEY | ||||||||
AuthorizedOfficialFirstName: | DELAINE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5055525305 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/09/2022 |
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 | H3451 | 05 | NM |   | MEDICAID | 320070 | 01 | NM | RAILROAD MEDICARE | OTHER |