Basic Information
| Provider Information | |||||||||
| NPI: | 1790118446 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUEBLO OF ZUNI | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | ZUNI TEEN HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 339 | ||||||||
| Address2: | |||||||||
| City: | ZUNI | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873270339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057825719 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 02 TWIN BUTTES DR | ||||||||
| Address2: | |||||||||
| City: | ZUNI | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873270000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057825719 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2013 | ||||||||
| LastUpdateDate: | 07/20/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KUCATE-YEPA | ||||||||
| AuthorizedOfficialFirstName: | MARNELLA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROGRAM MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5057825719 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PUEBLO OF ZUNI | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 11233371 | 05 | NM | MEDICAID |