Healthcare Provider Details

I. General information

NPI: 1578010070
Provider Name (Legal Business Name): CANONCITO BAND OF NAVAJOS HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 MEDICINE HORSE DRIVE
TOHAJIILEE NM
87026
US

IV. Provider business mailing address

129 MEDICINE HORSE DRIVE
TOHAJIILEE NM
87026
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 Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. BEVERLY LEWIS
Title or Position: BUSINESS OFFICE
Credential:
Phone: 505-908-2307