Basic Information
| Provider Information | |||||||||
| NPI: | 1740452697 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 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 NIZHONI BLVD | ||||||||
| Address2: | |||||||||
| City: | GALLUP | ||||||||
| State: | NM | ||||||||
| PostalCode: | 873015748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057221000 | ||||||||
| FaxNumber: | 5057221310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2008 | ||||||||
| LastUpdateDate: | 07/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | YAZZIE | ||||||||
| AuthorizedOfficialFirstName: | BENNIE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5057221403 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | 9435 | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 1507755 | 01 | NM | UCC GROUP NUMBER | OTHER |