Healthcare Provider Details

I. General information

NPI: 1477684447
Provider Name (Legal Business Name): JICARILLA EMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 NARROW GAUGE RD
DULCE NM
87528
US

IV. Provider business mailing address

POB 769 2300 NARROW GAUGE RD
DULCE NM
87528
US

V. Phone/Fax

Practice location:
  • Phone: 575-759-3778
  • Fax: 575-759-3841
Mailing address:
  • Phone: 575-759-3778
  • Fax: 575-759-3841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number47495
License Number StateNM

VIII. Authorized Official

Name: MRS. DAWN BURNS
Title or Position: ACTING DIRECTOR
Credential:
Phone: 575-759-3778