Basic Information
| Provider Information | |||||||||
| NPI: | 1861412777 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALAMO NAVAJO SCHOOL BOARD, INC. | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | ALAMO NAVAJO HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5907 | ||||||||
| Address2: | |||||||||
| City: | ALAMO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5758542626 | ||||||||
| FaxNumber: | 5758542528 | ||||||||
| Practice Location | |||||||||
| Address1: | MILEPOST 29, HIGHWAY 169 | ||||||||
| Address2: | |||||||||
| City: | ALAMO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5758542626 | ||||||||
| FaxNumber: | 5758542528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 06/20/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLLINS | ||||||||
| AuthorizedOfficialFirstName: | CLORA | ||||||||
| AuthorizedOfficialMiddleName: | PHYLLIS | ||||||||
| AuthorizedOfficialTitleorPosition: | HEALTH SERVICES DIRE | ||||||||
| AuthorizedOfficialTelephone: | 5758542626 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | J6136 | NM | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | AA2484931 | 01 | NM | DEA REG.NUMBER | OTHER | J6136 | 05 | NM | MEDICAID | AA2484931 | 01 | NM | DEA REG. NUMBER | OTHER | B5467 | 01 | NM | NM DRUG NUMBER | OTHER | 3210298 | 01 | NM | NABP NUMBER | OTHER |