Provider Demographics
NPI:1477684447
Name:JICARILLA EMS
Entity Type:Organization
Organization Name:JICARILLA EMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACTING DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-759-3778
Mailing Address - Street 1:POB 769
Mailing Address - Street 2:2300 NARROW GAUGE RD
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528
Mailing Address - Country:US
Mailing Address - Phone:575-759-3778
Mailing Address - Fax:575-759-3841
Practice Address - Street 1:2300 NARROW GAUGE RD
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528
Practice Address - Country:US
Practice Address - Phone:575-759-3778
Practice Address - Fax:575-759-3841
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JUCARILLA EMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-08
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM474953416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR134OtherBLUE CROSS BLUE SHIELD
NMR2939Medicaid