Healthcare Provider Details

I. General information

NPI: 1164851382
Provider Name (Legal Business Name): DJAA TLHENAI MEDICINE LODGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2013
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 CARLISLE BLVD SE
ALBUQUERQUE NM
87106-1427
US

IV. Provider business mailing address

POB 4682
ALBUQUERQUE NM
87196
US

V. Phone/Fax

Practice location:
  • Phone: 505-819-3403
  • Fax:
Mailing address:
  • Phone: 505-819-3403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number12-00116271
License Number StateNM

VIII. Authorized Official

Name: OATZINU SHEELAKEE
Title or Position: FOUNDER
Credential: IAMP
Phone: 505-819-3403