Healthcare Provider Details

I. General information

NPI: 1467739888
Provider Name (Legal Business Name): KEWA PUEBLO HEALTH CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2011
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 W HIGHWAY 22
SANTO DOMINGO PUEBLO NM
87052-0559
US

IV. Provider business mailing address

PO BOX 559
SANTO DOMINGO PUEBLO NM
87052-0559
US

V. Phone/Fax

Practice location:
  • Phone: 505-465-3060
  • Fax: 505-465-1191
Mailing address:
  • Phone: 505-465-3060
  • Fax: 505-465-1191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number03217726007
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: JIMMIE R CHARLIE
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 505-465-3060