Healthcare Provider Details

I. General information

NPI: 1477628659
Provider Name (Legal Business Name): INDIAN HEALTH SERVICE- JICARILLA SERVICE UNIT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12000 STONE LAKE DRIVE
DULCE NM
87528-0187
US

IV. Provider business mailing address

PO BOX 804
DULCE NM
87528-0804
US

V. Phone/Fax

Practice location:
  • Phone: 505-759-3291
  • Fax:
Mailing address:
  • Phone: 505-759-0440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MR. JIM SUTTON
Title or Position: CEO
Credential:
Phone: 505-759-3291