Provider Demographics
NPI:1508051061
Name:JICARILLA APACHE NATION
Entity Type:Organization
Organization Name:JICARILLA APACHE NATION
Other - Org Name:JICARILLA BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:PESATA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-759-3242
Mailing Address - Street 1:PO BOX 546
Mailing Address - Street 2:
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-0546
Mailing Address - Country:US
Mailing Address - Phone:505-759-3162
Mailing Address - Fax:505-759-3588
Practice Address - Street 1:109 SENECA DRIVE
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528
Practice Address - Country:US
Practice Address - Phone:505-759-3162
Practice Address - Fax:505-759-3588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health