Healthcare Provider Details

I. General information

NPI: 1336659077
Provider Name (Legal Business Name): KEWA PUEBLO HEALTH CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 10/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 WEST HIGHWAY 22
SANTO DOMINGO PUEBLO NM
87052
US

IV. Provider business mailing address

PO BOX 340
SANTO DOMINGO PUEBLO NM
87052-0340
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 505-465-3060
  • Fax: 505-465-1155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. SURAJ AGBOKE
Title or Position: BUSINESS OFIICE MANAGER
Credential:
Phone: 505-465-3060