Provider Demographics
NPI:1376632695
Name:SANTO DOMINGO HEALTH CLINIC
Entity Type:Organization
Organization Name:SANTO DOMINGO HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACTING CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRET
Authorized Official - Middle Name:A
Authorized Official - Last Name:SMOKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-988-9821
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:85 WEST HIGHWAY 22
Mailing Address - City:SANTO DOMINGO PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87052-0340
Mailing Address - Country:US
Mailing Address - Phone:505-465-3060
Mailing Address - Fax:505-465-1178
Practice Address - Street 1:85 WEST HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:SANTO DOMINGO PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87052-0340
Practice Address - Country:US
Practice Address - Phone:505-465-3060
Practice Address - Fax:505-465-1178
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SANTA FE INDIAN HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-12
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMH1232282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH1232Medicaid
NMH1232Medicaid
NMHSZ179Medicare PIN