Provider Demographics
NPI: | 1164851382 |
---|---|
Name: | DJAA TLHENAI MEDICINE LODGE |
Entity Type: | Organization |
Organization Name: | DJAA TLHENAI MEDICINE LODGE |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | FOUNDER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | OATZINU |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | SHEELAKEE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | IAMP |
Authorized Official - Phone: | 505-819-3403 |
Mailing Address - Street 1: | POB 4682 |
Mailing Address - Street 2: | |
Mailing Address - City: | ALBUQUERQUE |
Mailing Address - State: | NM |
Mailing Address - Zip Code: | 87196 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 505-819-3403 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 111 CARLISLE BLVD SE |
Practice Address - Street 2: | |
Practice Address - City: | ALBUQUERQUE |
Practice Address - State: | NM |
Practice Address - Zip Code: | 87106-1427 |
Practice Address - Country: | US |
Practice Address - Phone: | 505-819-3403 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | LI PA HENNE TRIBE |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2013-11-07 |
Last Update Date: | 2013-11-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NM | 12-00116271 | 174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist | Group - Multi-Specialty |