MEDICARE: TOWN OF COCHITI LAKE

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	3416L0300X	Land Ambulance

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558435990
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOWN OF COCHITI LAKE

Provider Business Mailing Address
First Line	:	PO BOX 641880
Second Line	:
City	:	OMAHA
State	:	NE
Zip	:	68164-7880
Country	:	US
Telephone Number	:	402-572-4019
Fax Number	:	888-506-4589

Provider Business Practice Location Address
First Line	:	6515C HOOCHANEETSA BLVD
Second Line	:
City	:	COCHITI LAKE
State	:	NM
Zip	:	87083-6031
Country	:	US
Telephone Number	:	505-465-2421
Fax Number	:

Authorized Official
Title or Position	:	CHIEF
Name	:	MR. JOHN W GURULE
Credential	:
Telephone Number	:	505-697-0484

Provider Enumeration Date	:	11/18/2006
Last Update Date	:	09/21/2017

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Directions to “TOWN OF COCHITI LAKE ” Practice Location

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