Provider Demographics
NPI:1073110920
Name:NAMBE PUEBLO
Entity Type:Organization
Organization Name:NAMBE PUEBLO
Other - Org Name:TEWA ROOTS SOCIETY
Other - Org Type:Other Name
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:505-455-5591
Mailing Address - Street 1:15A BAY POE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506-2731
Mailing Address - Country:US
Mailing Address - Phone:505-455-5591
Mailing Address - Fax:
Practice Address - Street 1:16A TAYEH HUU U
Practice Address - Street 2:
Practice Address - City:PUEBLO OF NAMBE
Practice Address - State:NM
Practice Address - Zip Code:87506
Practice Address - Country:US
Practice Address - Phone:505-455-5591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-05
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM39059839Medicaid