Provider Demographics
NPI:1225103922
Name:ACOMA-CANONCITO-LAGUNA INDIAN HEALTH CENTER
Entity Type:Organization
Organization Name:ACOMA-CANONCITO-LAGUNA INDIAN HEALTH CENTER
Other - Org Name:ACOMA CANONCITO LAGUNA INDIAN
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:DELAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-552-5305
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:SAN FIDEL
Mailing Address - State:NM
Mailing Address - Zip Code:87049-0130
Mailing Address - Country:US
Mailing Address - Phone:505-552-5300
Mailing Address - Fax:505-552-5490
Practice Address - Street 1:80 B VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:ACOMA
Practice Address - State:NM
Practice Address - Zip Code:87034
Practice Address - Country:US
Practice Address - Phone:505-552-5300
Practice Address - Fax:505-552-5490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH3451Medicaid
NM320070OtherRAILROAD MEDICARE
NM320070Medicare Oscar/Certification
NMHSZ023Medicare PIN
NM320070OtherRAILROAD MEDICARE