Healthcare Provider Details

I. General information

NPI: 1932267259
Provider Name (Legal Business Name): PUEBLO OF LAGUNA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 10/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 BLUE STAR LOOP
PARAJE NM
87007
US

IV. Provider business mailing address

PO BOX 179
LAGUNA NM
87026-0179
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-1102
  • Fax: 505-552-6577
Mailing address:
  • Phone: 505-552-5796
  • Fax: 505-552-6941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number54194
License Number StateNM

VIII. Authorized Official

Name: MR. MILES KING
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 505-552-5779