Basic Information
Provider Information | |||||||||
NPI: | 1649331323 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SANTA ANA HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 801 VASSAR DRIVE NE | ||||||||
Address2: |   | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 87106 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5058672497 | ||||||||
FaxNumber: | 5052487701 | ||||||||
Practice Location | |||||||||
Address1: | 02C DOVE ROAD | ||||||||
Address2: |   | ||||||||
City: | BERNALILLO | ||||||||
State: | NM | ||||||||
PostalCode: | 87004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5058672497 | ||||||||
FaxNumber: | 5058671526 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/13/2006 | ||||||||
LastUpdateDate: | 04/10/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALEXANDER | ||||||||
AuthorizedOfficialFirstName: | JACQUELINE | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | CEO, ACTING | ||||||||
AuthorizedOfficialTelephone: | 5052484062 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ALBUQUERQUE INDIAN HEALTH CENTER | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | 31174256 | 05 | NM |   | MEDICAID | HSZ159 | 01 | NM | GROUP | OTHER |