Healthcare Provider Details

I. General information

NPI: 1790802890
Provider Name (Legal Business Name): TAOS PICURIS HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 GOAT SPRINGS RD
TAOS NM
87571
US

IV. Provider business mailing address

PO BOX 95452
CLEVELAND OH
44101-0033
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-6995
  • Fax: 505-751-5211
Mailing address:
  • Phone: 575-758-6995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KAILEE FRETLAND
Title or Position: PRINCIPAL PHARMACY CONSULTANT
Credential: PHARMD
Phone: 240-478-2245