Healthcare Provider Details

I. General information

NPI: 1790539542
Provider Name (Legal Business Name): CANONCITO BAND OF NAVAJOS HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2024
Last Update Date: 04/16/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 MEDICINE HORSE DRIVE
TO'HAJIILEE NM
87026-3528
US

IV. Provider business mailing address

PO BOX 3528
TOHAJIILEE NM
87026-3528
US

V. Phone/Fax

Practice location:
  • Phone: 505-908-2307
  • Fax: 505-908-2310
Mailing address:
  • Phone: 505-908-2307
  • Fax: 505-908-2310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: SHERYL O'SHEA
Title or Position: CHIEF MEDICAL OFFICER
Credential: M.D.
Phone: 505-908-2307