Healthcare Provider Details

I. General information

NPI: 1184855504
Provider Name (Legal Business Name): PUEBLO DE COCHITI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2009
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 COCHITI ST
COCHITI PUEBLO NM
87072-9998
US

IV. Provider business mailing address

255 COCHITI ST
COCHITI PUEBLO NM
87072-9998
US

V. Phone/Fax

Practice location:
  • Phone: 505-465-2244
  • Fax: 505-465-1135
Mailing address:
  • Phone: 505-465-2244
  • Fax: 505-465-1135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNM

VIII. Authorized Official

Name: PHILIP QUINTANA
Title or Position: GOVERNOR
Credential:
Phone: 505-465-2244