Basic Information
| Provider Information | |||||||||
| NPI: | 1679614598 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIAN HEALTH SERVICE | ||||||||
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| OtherOrganizationName: | PUEBLO OF SANDIA HEALTH & SOCIAL SVCS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5805 RIO LAMA RD NE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871446014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059944478 | ||||||||
| FaxNumber: | 5057715107 | ||||||||
| Practice Location | |||||||||
| Address1: | 481 SANDIA LOOP | ||||||||
| Address2: | PUEBLO OF SANDIA | ||||||||
| City: | BERNALILLO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870047076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057715116 | ||||||||
| FaxNumber: | 5057715107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BENFORD-WOSKOFF | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5057715116 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP0904X | Y | Ambulatory Health Care Facilities | Clinic/Center | Public Health, Federal |
No ID Information.