Healthcare Provider Details

I. General information

NPI: 1346326600
Provider Name (Legal Business Name): JICARILLA APACHE HEALTH CARE FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 STONE LAKE RD
DULCE NM
87528-0187
US

IV. Provider business mailing address

12000 STONE LAKE RD. P.O. BOX 127
DULCE NM
87528-0127
US

V. Phone/Fax

Practice location:
  • Phone: 505-759-7258
  • Fax: 505-759-7258
Mailing address:
  • Phone: 505-759-7258
  • Fax: 505-759-7287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberL10182
License Number StateNM

VIII. Authorized Official

Name: MRS. BARRI REA HERBEL
Title or Position: URGENT CARE NURSE
Credential: LPN
Phone: 505-759-7258