Healthcare Provider Details

I. General information

NPI: 1225346547
Provider Name (Legal Business Name): PUEBLO OF JEMEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2010
Last Update Date: 07/21/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 SHEEP SPRINGS WAY
JEMEZ PUEBLO NM
87024
US

IV. Provider business mailing address

PO BOX 279
JEMEZ PUEBLO NM
87024-0279
US

V. Phone/Fax

Practice location:
  • Phone: 575-834-7413
  • Fax: 575-834-7517
Mailing address:
  • Phone: 575-834-7413
  • Fax: 575-834-7517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberEXEMPT
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNM

VIII. Authorized Official

Name: NOHEMY ROSALES
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 575-834-3187