Provider Demographics
NPI:1003820069
Name:JICARILLA HEALTH CARE FACILITY
Entity Type:Organization
Organization Name:JICARILLA HEALTH CARE FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PUBLIC HEALTH NURSE
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:T
Authorized Official - Last Name:PRYOR
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:505-759-7286
Mailing Address - Street 1:PO BOX 1144
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-1144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12000 STONE LAKE RD
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528
Practice Address - Country:US
Practice Address - Phone:505-759-7286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health