Provider Demographics
NPI:1184855504
Name:PUEBLO DE COCHITI
Entity Type:Organization
Organization Name:PUEBLO DE COCHITI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GOVERNOR
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINTANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-465-2244
Mailing Address - Street 1:255 COCHITI ST
Mailing Address - Street 2:
Mailing Address - City:COCHITI PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87072-9998
Mailing Address - Country:US
Mailing Address - Phone:505-465-2244
Mailing Address - Fax:505-465-1135
Practice Address - Street 1:255 COCHITI ST
Practice Address - Street 2:
Practice Address - City:COCHITI PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87072-9998
Practice Address - Country:US
Practice Address - Phone:505-465-2244
Practice Address - Fax:505-465-1135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-03
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X
NM343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)