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General NPI Number Information
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NPI Number | 1164851382
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Entity Type | Organization
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Legal Business Name | DJAA TLHENAI MEDICINE LODGE
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Dates
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Enumeration Date | 11/07/2013
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Last Update Date | 11/07/2013
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Provider Practice Location Address
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Address Line | 111 CARLISLE BLVD SE
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City | ALBUQUERQUE
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State | NM
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Zip | 87106-1427
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Country | US
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Telephone | 505-819-3403
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Fax |
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Provider Business Mailing Address
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Address Line | POB 4682
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City | ALBUQUERQUE
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State | NM
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Zip | 87196
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Country | US
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Telephone | 505-819-3403
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Fax |
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Authorized Official
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Title or Position | FOUNDER
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Name | OATZINU SHEELAKEE
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Credential | IAMP
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Telephone | 505-819-3403
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 12-00116271
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License Number State | NM
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