MEDICARE: DJAA TLHENAI MEDICINE LODGE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	12-00116271	NM

General Provider Information

NPI Number	:	1164851382
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DJAA TLHENAI MEDICINE LODGE

Provider Business Mailing Address
First Line	:	POB 4682
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87196
Country	:	US
Telephone Number	:	505-819-3403
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 CARLISLE BLVD SE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-1427
Country	:	US
Telephone Number	:	505-819-3403
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER
Name	:	OATZINU SHEELAKEE
Credential	:	IAMP
Telephone Number	:	505-819-3403

Provider Enumeration Date	:	11/07/2013
Last Update Date	:	11/07/2013

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