Basic Information
| Provider Information | |||||||||
| NPI: | 1932199171 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FIRST NATIONS COMMUNITY HEALTH SOURCE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5608 ZUNI RD SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871082926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052626523 | ||||||||
| FaxNumber: | 5052657045 | ||||||||
| Practice Location | |||||||||
| Address1: | 5608 ZUNI RD SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871082926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052626523 | ||||||||
| FaxNumber: | 5052657045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 03/02/2009 | ||||||||
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| AuthorizedOfficialLastName: | SON-STONE | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5052626546 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 46912 | 05 | NM | MEDICAID |