Basic Information
| Provider Information | |||||||||
| NPI: | 1649462532 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACOMA CANONCITO LAGUNA INDIAN | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DHHS USPHS INDIAN HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | ACOMA CANONCITO LAGUNA INDIAN HOSPITAL | ||||||||
| City: | SAN FIDEL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870490130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055525385 | ||||||||
| FaxNumber: | 5055525490 | ||||||||
| Practice Location | |||||||||
| Address1: | EXIT 102 OFF I-40 1/2 MI SOUTH | ||||||||
| Address2: | |||||||||
| City: | SAN FIDEL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870490130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055525385 | ||||||||
| FaxNumber: | 5055525490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2007 | ||||||||
| LastUpdateDate: | 01/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | FELIPE | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ACL IHS CEO | ||||||||
| AuthorizedOfficialTelephone: | 5055525303 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 14909596 | NM | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 14909596 | 05 | NM | MEDICAID | 320070 | 01 | MEDICARE PART A | OTHER |