Provider Demographics
NPI:1417472192
Name:FNCH OUTPATIENT SERVICES
Entity Type:Organization
Organization Name:FNCH OUTPATIENT SERVICES
Other - Org Name:FNCH OUTPATIENT SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SUZETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-262-6567
Mailing Address - Street 1:5608 ZUNI RD SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-2926
Mailing Address - Country:US
Mailing Address - Phone:505-262-2481
Mailing Address - Fax:505-265-7045
Practice Address - Street 1:634 MANZANO STREET NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-262-2481
Practice Address - Fax:505-265-7045
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FIRST NATIONS COMMUNITY HEALTH SOURCE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-03
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0004-6912Medicaid