Healthcare Provider Details

I. General information

NPI: 1548597743
Provider Name (Legal Business Name): DHHS/IHS/AAO/JSU/DULCE HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2009
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 STONE LAKE ROAD JICARILLA SERVICE UNIT
DULCE NM
87528
US

IV. Provider business mailing address

P O BOX 187 12000 STONE LAKE ROAD
DULCE NM
87528-0187
US

V. Phone/Fax

Practice location:
  • Phone: 575-759-3291
  • Fax: 575-759-3532
Mailing address:
  • Phone: 575-759-3291
  • Fax: 575-759-3532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number18451
License Number StateCO

VIII. Authorized Official

Name: CHARLENE HAMILTON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 575-759-7200