Healthcare Provider Details

I. General information

NPI: 1679007744
Provider Name (Legal Business Name): EIGHT NORTHERN INDIAN PUEBLOS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

579 WHITE SWAN RD 327 EAGLE DRIVE
OHKAY OWINGEH NM
87566
US

IV. Provider business mailing address

PO BOX 969 327 EAGLE DRIVE
OHKAY OWINGEH NM
87566-0969
US

V. Phone/Fax

Practice location:
  • Phone: 505-852-2788
  • Fax:
Mailing address:
  • Phone: 575-751-7688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. DOROTHY ANNE FORBES
Title or Position: PROGRAM DIRECTOR
Credential: LCSW
Phone: 505-692-5034