Healthcare Provider Details

I. General information

NPI: 1609913961
Provider Name (Legal Business Name): PUEBLO OF JEMEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4535 HIGHWAY 4
JEMEZ PUEBLO NM
87024-0219
US

IV. Provider business mailing address

4535 HIGHWAY 4
JEMEZ PUEBLO NM
87024-0219
US

V. Phone/Fax

Practice location:
  • Phone: 575-834-7359
  • Fax:
Mailing address:
  • Phone: 575-834-7359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number124046
License Number StateNM

VIII. Authorized Official

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