Healthcare Provider Details

I. General information

NPI: 1396944211
Provider Name (Legal Business Name): SANTO DOMINGO PUEBLO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 EAGLE CT # 87052
SANTO DOMINGO PUEBLO NM
87052-1230
US

IV. Provider business mailing address

PO BOX 130
SANTO DOMINGO PUEBLO NM
87052-0130
US

V. Phone/Fax

Practice location:
  • Phone: 505-465-2733
  • Fax:
Mailing address:
  • Phone: 505-465-2733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: LUCAS JEROME O'LAUGHLIN
Title or Position: DIRECTOR
Credential:
Phone: 505-709-8259