Provider Demographics
NPI:1225346547
Name:PUEBLO OF JEMEZ
Entity Type:Organization
Organization Name:PUEBLO OF JEMEZ
Other - Org Name:DBA JEMEZ FQHC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NOHEMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-834-3187
Mailing Address - Street 1:PO BOX 279
Mailing Address - Street 2:
Mailing Address - City:JEMEZ PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87024-0279
Mailing Address - Country:US
Mailing Address - Phone:575-834-7413
Mailing Address - Fax:575-834-7517
Practice Address - Street 1:110 SHEEP SPRINGS WAY
Practice Address - Street 2:
Practice Address - City:JEMEZ PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87024
Practice Address - Country:US
Practice Address - Phone:575-834-7413
Practice Address - Fax:575-834-7517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM261Q00000X
NMEXEMPT261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMSP6492Medicare PIN
NMTEZ109Medicare PIN
NM321910Medicare PIN