Provider Demographics
NPI:1114040714
Name:PUEBLO OF ISLETA
Entity Type:Organization
Organization Name:PUEBLO OF ISLETA
Other - Org Name:ISLETA HEALTH CENTER BH
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 912157
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80291-2157
Mailing Address - Country:US
Mailing Address - Phone:505-869-4863
Mailing Address - Fax:505-869-4811
Practice Address - Street 1:01 SAGEBRUSH ST
Practice Address - Street 2:
Practice Address - City:ISLETA
Practice Address - State:NM
Practice Address - Zip Code:87022-0000
Practice Address - Country:US
Practice Address - Phone:505-869-4863
Practice Address - Fax:505-869-4811
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUEBLO OF ISLETA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-09
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM501C101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM3803775Medicaid