Provider Demographics
NPI:1407147994
Name:SANTA CLARA PUEBLO
Entity Type:Organization
Organization Name:SANTA CLARA PUEBLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LT. GOVERNOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:TAFOYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-753-7326
Mailing Address - Street 1:P.O. BOX 580
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532
Mailing Address - Country:US
Mailing Address - Phone:505-753-7326
Mailing Address - Fax:
Practice Address - Street 1:360 FOG ROAD
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532
Practice Address - Country:US
Practice Address - Phone:505-753-7326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty