Provider Demographics
NPI:1326590191
Name:PUEBLO OF ISLETA
Entity Type:Organization
Organization Name:PUEBLO OF ISLETA
Other - Org Name:PUEBLO OF ISLETA URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VOLELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAMORA
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:505-869-4094
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:ISLETA
Mailing Address - State:NM
Mailing Address - Zip Code:87022-0640
Mailing Address - Country:US
Mailing Address - Phone:505-869-3200
Mailing Address - Fax:505-869-4881
Practice Address - Street 1:01 SAGEBRUSH
Practice Address - Street 2:
Practice Address - City:ISLETA
Practice Address - State:NM
Practice Address - Zip Code:87022
Practice Address - Country:US
Practice Address - Phone:505-869-3200
Practice Address - Fax:505-869-4881
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUEBLO OF ISLETA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM=========OtherIN PROCESS