Healthcare Provider Details

I. General information

NPI: 1063643237
Provider Name (Legal Business Name): MCKINLEY COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2009
Last Update Date: 08/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 W HILL AVE
GALLUP NM
87301-4615
US

IV. Provider business mailing address

PO BOX 70
GALLUP NM
87305-0070
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-1400
  • Fax:
Mailing address:
  • Phone: 505-863-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: TOM TRUJILLO
Title or Position: COUNTY MANAGER
Credential:
Phone: 505-863-1400