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General NPI Number Information
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NPI Number | 1881020089
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Entity Type | Organization
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Legal Business Name | JICARILLA APACHE NATION
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Dates
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Enumeration Date | 09/19/2013
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Last Update Date | 05/20/2015
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Provider Practice Location Address
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Address Line | 450 N MUNDO DR.
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City | DULCE
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State | NM
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Zip | 87528
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Country | US
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Telephone | 575-759-4206
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Fax | 575-759-4471
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Provider Business Mailing Address
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Address Line | 450 N MUNDO DR.
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City | DULCE
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State | NM
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Zip | 87528
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Country | US
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Telephone | 575-759-4206
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Fax | 575-759-4471
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Authorized Official
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Title or Position | PRESIDENT
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Name | TY VICENTI
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Credential |
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Telephone | 575-759-4201
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0700X
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Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
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License Number |
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License Number State |
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