Provider Demographics
NPI:1184208225
Name:PUEBLO DE SAN ILDEFONSO
Entity Type:Organization
Organization Name:PUEBLO DE SAN ILDEFONSO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR HEALTH AND HUMAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:505-692-5943
Mailing Address - Street 1:2 TUNYO PO
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506-7258
Mailing Address - Country:US
Mailing Address - Phone:505-455-2395
Mailing Address - Fax:
Practice Address - Street 1:2 TUNYO PO
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87506-7258
Practice Address - Country:US
Practice Address - Phone:505-455-2395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-05
Last Update Date:2022-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or LocalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1437615564Medicaid