Healthcare Provider Details

I. General information

NPI: 1093883787
Provider Name (Legal Business Name): JJDAC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 08/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 NIZHONI BLVD
GALLUP NM
87301
US

IV. Provider business mailing address

PO BOX 610
GALLUP NM
87305-0511
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-5295
  • Fax: 505-722-6426
Mailing address:
  • Phone: 505-722-5295
  • Fax: 505-722-6426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code341600000X
TaxonomyAmbulance
License Number51164
License Number StateNM

VIII. Authorized Official

Name: MR. ERIC THOMAS
Title or Position: SVP OF REVENUE MANAGEMENT
Credential:
Phone: 877-288-5340