Basic Information
| Provider Information | |||||||||
| NPI: | 1902875594 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DHHS, PHS, NAIHS, GALLUP INDIAN MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TOHATCHI HEALTH CENTER | ||||||||
| 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: | 007 CHOOSGAI DRIVE | ||||||||
| Address2: | |||||||||
| City: | TOHATCHI | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057221000 | ||||||||
| FaxNumber: | 5057221310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 02/09/2012 | ||||||||
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| AuthorizedOfficialLastName: | YAZZIE | ||||||||
| AuthorizedOfficialFirstName: | BENNIE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | ACTING CEO | ||||||||
| AuthorizedOfficialTelephone: | 5057221000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP0904X | 9435 | Y | Ambulatory Health Care Facilities | Clinic/Center | Public Health, Federal |
ID Information
| ID | Type | State | Issuer | Description | 06286518 | 05 | NM | MEDICAID | 061135 | 05 | AZ | MEDICAID |