Healthcare Provider Details

I. General information

NPI: 1033954425
Provider Name (Legal Business Name): CIBOLA GENERAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2024
Last Update Date: 06/27/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 BONITA AVE
GRANTS NM
87020
US

IV. Provider business mailing address

1423 E ROOSEVELT AVE
GRANTS NM
87020
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-6500
  • Fax: 505-287-5393
Mailing address:
  • Phone: 505-287-6500
  • Fax: 505-287-5393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT CLELAND
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 505-287-6500