Provider Demographics
NPI:1326217043
Name:DHHS,PHS,NAIHS,GALLUP INDIAN MEDICAL CENTER
Entity Type:Organization
Organization Name:DHHS,PHS,NAIHS,GALLUP INDIAN MEDICAL CENTER
Other - Org Name:LITTLE SISTERS OF THE POOR OF NEW MEXICO, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BENNIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:YAZZIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-722-1402
Mailing Address - Street 1:PO BOX 1337
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:505-722-1310
Practice Address - Street 1:1900 MARK AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-4822
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-722-1310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
9435310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHSZ003Medicare PIN