Healthcare Provider Details

I. General information

NPI: 1770708174
Provider Name (Legal Business Name): ISLETA ELDERLY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TRIBAL RD. 40 BLDG. 70
ISLETA NM
87022
US

IV. Provider business mailing address

PO BOX 1270
ISLETA NM
87022-1270
US

V. Phone/Fax

Practice location:
  • Phone: 505-869-6661
  • Fax: 505-869-2736
Mailing address:
  • Phone: 505-869-6661
  • Fax: 505-869-2736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. KATHY BLACK
Title or Position: DIRECTOR
Credential: M.S.
Phone: 505-869-6661