Healthcare Provider Details

I. General information

NPI: 1558435990
Provider Name (Legal Business Name): TOWN OF COCHITI LAKE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2006
Last Update Date: 09/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6515C HOOCHANEETSA BLVD
COCHITI LAKE NM
87083-6031
US

IV. Provider business mailing address

PO BOX 641880
OMAHA NE
68164-7880
US

V. Phone/Fax

Practice location:
  • Phone: 505-465-2421
  • Fax:
Mailing address:
  • Phone: 402-572-4019
  • Fax: 888-506-4589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN W GURULE
Title or Position: CHIEF
Credential:
Phone: 505-697-0484