Provider Demographics
NPI:1457675266
Name:CIBOLA GENERAL HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:CIBOLA GENERAL HOSPITAL CORPORATION
Other - Org Name:CIBOLA FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROJAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-287-5202
Mailing Address - Street 1:1423 E ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2245
Mailing Address - Country:US
Mailing Address - Phone:505-287-6500
Mailing Address - Fax:505-287-5393
Practice Address - Street 1:1423 E ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2245
Practice Address - Country:US
Practice Address - Phone:505-287-6500
Practice Address - Fax:505-287-5393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM323409OtherMEDICARE PTAN
NM63306514Medicaid