Provider Demographics
NPI:1477628659
Name:INDIAN HEALTH SERVICE- JICARILLA SERVICE UNIT
Entity Type:Organization
Organization Name:INDIAN HEALTH SERVICE- JICARILLA SERVICE UNIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-759-3291
Mailing Address - Street 1:PO BOX 804
Mailing Address - Street 2:
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-0804
Mailing Address - Country:US
Mailing Address - Phone:505-759-0440
Mailing Address - Fax:
Practice Address - Street 1:12000 STONE LAKE DRIVE
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528-0187
Practice Address - Country:US
Practice Address - Phone:505-759-3291
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory