Healthcare Provider Details

I. General information

NPI: 1881020089
Provider Name (Legal Business Name): JICARILLA APACHE NATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 05/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 N MUNDO DR.
DULCE NM
87528
US

IV. Provider business mailing address

450 N MUNDO DR.
DULCE NM
87528
US

V. Phone/Fax

Practice location:
  • Phone: 575-759-4206
  • Fax: 575-759-4471
Mailing address:
  • Phone: 575-759-4206
  • Fax: 575-759-4471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TY VICENTI
Title or Position: PRESIDENT
Credential:
Phone: 575-759-4201