Provider Demographics
NPI:1023191368
Name:PUEBLO OF ISLETA
Entity Type:Organization
Organization Name:PUEBLO OF ISLETA
Other - Org Name:PUEBLOF OF ISLETA EMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:VOLELLE
Authorized Official - Middle Name:K
Authorized Official - Last Name:ZAMORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-869-4094
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:ISLETA
Mailing Address - State:NM
Mailing Address - Zip Code:87022
Mailing Address - Country:US
Mailing Address - Phone:505-869-4863
Mailing Address - Fax:505-869-4881
Practice Address - Street 1:01 SAGEBRUSH
Practice Address - Street 2:
Practice Address - City:ISLETA
Practice Address - State:NM
Practice Address - Zip Code:87022
Practice Address - Country:US
Practice Address - Phone:505-869-4863
Practice Address - Fax:505-869-4881
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUEBLO OF ISLETA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-23
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM39284341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000R2759Medicaid
NM000R2759Medicaid