=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780677039
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CIBOLA GENERAL HOSPITAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2005
-----------------------------------------------------
Last Update Date | 08/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1016 E ROOSEVELT AVE
-----------------------------------------------------
City | GRANTS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87020-2118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-287-5300
-----------------------------------------------------
Fax | 505-287-5309
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1016 E ROOSEVELT AVE
-----------------------------------------------------
City | GRANTS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87020-2118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-287-5300
-----------------------------------------------------
Fax | 505-287-5309
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | DONNA ROJAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-287-5202
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 282NC0060X
-----------------------------------------------------
Taxonomy Name | Critical Access Hospital
-----------------------------------------------------
License Number | 6079
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------