Healthcare Provider Details

I. General information

NPI: 1508051061
Provider Name (Legal Business Name): JICARILLA APACHE NATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 09/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 SENECA DRIVE
DULCE NM
87528
US

IV. Provider business mailing address

PO BOX 546
DULCE NM
87528-0546
US

V. Phone/Fax

Practice location:
  • Phone: 505-759-3162
  • Fax: 505-759-3588
Mailing address:
  • Phone: 505-759-3162
  • Fax: 505-759-3588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. LEVI PESATA
Title or Position: PRESIDENT
Credential:
Phone: 505-759-3242