MEDICARE: CIBOLA GENERAL HOSPITAL CORPORATION

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	282NC0060X	Critical Access Hospital	6079	NM

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	321308	OTHER	NM	MEDICARE ID - UNSPECIFIED

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	:	1780677039
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CIBOLA GENERAL HOSPITAL CORPORATION

Provider Business Mailing Address
First Line	:	1016 E ROOSEVELT AVE
Second Line	:
City	:	GRANTS
State	:	NM
Zip	:	87020-2118
Country	:	US
Telephone Number	:	505-287-5300
Fax Number	:	505-287-5309

Provider Business Practice Location Address
First Line	:	1016 E ROOSEVELT AVE
Second Line	:
City	:	GRANTS
State	:	NM
Zip	:	87020-2118
Country	:	US
Telephone Number	:	505-287-5300
Fax Number	:	505-287-5309

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	DONNA ROJAS
Credential	:
Telephone Number	:	505-287-5202

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	08/18/2020

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Practice Location Address:

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Practice Location Address:

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Directions to “CIBOLA GENERAL HOSPITAL CORPORATION ” Practice Location

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