Provider Demographics
NPI:1467739888
Name:KEWA PUEBLO HEALTH CORPORATION
Entity Type:Organization
Organization Name:KEWA PUEBLO HEALTH CORPORATION
Other - Org Name:SANTO DOMINGO HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JIMMIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:CHARLIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-465-3060
Mailing Address - Street 1:PO BOX 559
Mailing Address - Street 2:
Mailing Address - City:SANTO DOMINGO PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87052-0559
Mailing Address - Country:US
Mailing Address - Phone:505-465-3060
Mailing Address - Fax:505-465-1191
Practice Address - Street 1:85 W HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:SANTO DOMINGO PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87052-0559
Practice Address - Country:US
Practice Address - Phone:505-465-3060
Practice Address - Fax:505-465-1191
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEWA PUEBLO HEALTH CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-14
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM03217726007261Q00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center