Basic Information
| Provider Information | |||||||||
| NPI: | 1548588643 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUEBLO OF SANDIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | SANDIA HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 481 SANDIA LOOP | ||||||||
| Address2: | |||||||||
| City: | BERNALILLO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870047076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058674696 | ||||||||
| FaxNumber: | 5058674997 | ||||||||
| Practice Location | |||||||||
| Address1: | 203 SANDIA DAY SCHOOL ROAD | ||||||||
| Address2: | |||||||||
| City: | BERNALILLO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870047076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058674696 | ||||||||
| FaxNumber: | 5057715107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2010 | ||||||||
| LastUpdateDate: | 04/07/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, HEALTH AND SOCIAL SERVICE | ||||||||
| AuthorizedOfficialTelephone: | 5057715092 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | 04/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 332800000X | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 35922079 | 05 | NM | MEDICAID |