Provider Demographics
NPI:1134465024
Name:INDIGENOUS INNOVATIONS
Entity Type:Organization
Organization Name:INDIGENOUS INNOVATIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:BARBER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:505-686-4903
Mailing Address - Street 1:PO BOX 2885
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND
Mailing Address - State:NM
Mailing Address - Zip Code:87417-2885
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:913 W APACHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-3899
Practice Address - Country:US
Practice Address - Phone:505-686-4903
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-20
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNMPRC 56258343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM70727066Medicaid
AZ763448Medicaid