Healthcare Provider Details

I. General information

NPI: 1770027641
Provider Name (Legal Business Name): STUART JONES LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 PINSBAARI DR.
PUEBLO OF ACOMA NM
87034
US

IV. Provider business mailing address

PO BOX 328
PUEBLO OF ACOMA NM
87034-0328
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-6661
  • Fax: 505-552-6427
Mailing address:
  • Phone: 505-552-6661
  • Fax: 505-552-6427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0129501
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: