Basic Information
| Provider Information | |||||||||
| NPI: | 1326217043 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DHHS,PHS,NAIHS,GALLUP INDIAN MEDICAL CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| NamePrefix: | |||||||||
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| OtherOrganizationName: | LITTLE SISTERS OF THE POOR OF NEW MEXICO, INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 1900 MARK AVE | ||||||||
| Address2: | |||||||||
| City: | GALLUP | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873014822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057221000 | ||||||||
| FaxNumber: | 5057221310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2008 | ||||||||
| LastUpdateDate: | 07/16/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | YAZZIE | ||||||||
| AuthorizedOfficialFirstName: | BENNIE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5057221402 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 9435 | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.