Healthcare Provider Details

I. General information

NPI: 1952505208
Provider Name (Legal Business Name): GALLUP INDIAN MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 B SHUSH DRIVE EXIT 33 STATE ROAD 400
FT . WINGATE NM
87316
US

IV. Provider business mailing address

516 E. NIZHONI BLVD
GALLUP NM
87301-1337
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1770
  • Fax: 505-722-1796
Mailing address:
  • Phone: 505-722-1770
  • Fax: 505-722-1796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number9435
License Number State

VIII. Authorized Official

Name: BENNIE C. YAZZIE
Title or Position: ACTING CEO
Credential:
Phone: 505-722-1000