Healthcare Provider Details

I. General information

NPI: 1023051133
Provider Name (Legal Business Name): PUEBLO PINTADO CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 10/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#10 PUEBLO PINTADO SCHOOL
CUBA NM
87013
US

IV. Provider business mailing address

PO BOX 358
CROWNPOINT NM
87313-0358
US

V. Phone/Fax

Practice location:
  • Phone: 505-655-3501
  • Fax: 505-862-8909
Mailing address:
  • Phone: 505-655-6501
  • Fax: 505-655-3510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ANSLEM ROANHORSE
Title or Position: CEO
Credential:
Phone: 505-786-5291