Healthcare Provider Details

I. General information

NPI: 1073138244
Provider Name (Legal Business Name): HASTAADI NEEZNADIIN DBA GALLUP HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 E HISTORIC HIGHWAY 66
GALLUP NM
87301-5466
US

IV. Provider business mailing address

1108 E HISTORIC HIGHWAY 66
GALLUP NM
87301-5466
US

V. Phone/Fax

Practice location:
  • Phone: 505-726-9642
  • Fax: 505-726-9642
Mailing address:
  • Phone: 505-726-9642
  • Fax: 505-726-9642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. SCOTT DANIEL BURGNER
Title or Position: DIRECTOR
Credential:
Phone: 505-726-9642