Basic Information
| Provider Information | |||||||||
| NPI: | 1225002322 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DHHS,PHS,NAIHS, GALLUP INDIAN MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1337 | ||||||||
| Address2: | |||||||||
| City: | GALLUP | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873051337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057221000 | ||||||||
| FaxNumber: | 5057221310 | ||||||||
| Practice Location | |||||||||
| Address1: | 516 E. NIZHONI BLVD. | ||||||||
| Address2: | |||||||||
| City: | GALLUP | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873011337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057221000 | ||||||||
| FaxNumber: | 5057221310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 05/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | YAZZIE | ||||||||
| AuthorizedOfficialFirstName: | BENNIE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5057221000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311Z00000X | N | Nursing & Custodial Care Facilities | Custodial Care Facility | 282N00000X | 9435 | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | H5670 | 05 | NM | MEDICAID |