Basic Information
| Provider Information | |||||||||
| NPI: | 1619001849 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RAMAH NAVAJO SCHOOL BOARD, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PINE HILL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 310 | ||||||||
| Address2: | |||||||||
| City: | PINE HILL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873570310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057753271 | ||||||||
| FaxNumber: | 5057753233 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 BIA 120 | ||||||||
| Address2: | PO BOX 310 | ||||||||
| City: | PINE HILL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873570310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057753271 | ||||||||
| FaxNumber: | 5057753233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2007 | ||||||||
| LastUpdateDate: | 09/27/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BECKER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF HEALTH ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5057753271 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332800000X | N | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy | 3416L0300X | NM | N | Transportation Services | Ambulance | Land Transport | 261QF0400X | NM | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 00055587 | 05 | NM | MEDICAID | R0829 | 05 | NM | MEDICAID |