Healthcare Provider Details

I. General information

NPI: 1679716419
Provider Name (Legal Business Name): PUEBLO OF ACOMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 04/25/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

74 PINSBAARI DR
ACOMA NM
87034-1001
US

IV. Provider business mailing address

PO BOX 641880
OMAHA NE
68164-7880
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-7500
  • Fax: 505-552-9470
Mailing address:
  • Phone: 402-991-7866
  • Fax: 505-552-9470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number54980
License Number StateNM

VIII. Authorized Official

Name: MR. BARBARA A VAUGHN
Title or Position: AGENT
Credential:
Phone: 402-991-7866