Healthcare Provider Details

I. General information

NPI: 1265511299
Provider Name (Legal Business Name): PUEBLO OF SAN FELIPE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 CEDAR RD.
SAN FELIPE NM
87001
US

IV. Provider business mailing address

PO BOX 4339
SAN FELIPE NM
87001
US

V. Phone/Fax

Practice location:
  • Phone: 505-867-9616
  • Fax: 505-771-9992
Mailing address:
  • Phone: 505-867-9616
  • Fax: 505-771-9992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BRUCE D. GARCIA
Title or Position: PUEBLO OF SAN FELIPE TRIBAL ADMIN
Credential:
Phone: 505-867-3381