Provider Demographics
NPI:1548597743
Name:DHHS/IHS/AAO/JSU/DULCE HEALTH CENTER
Entity Type:Organization
Organization Name:DHHS/IHS/AAO/JSU/DULCE HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-759-7200
Mailing Address - Street 1:P O BOX 187
Mailing Address - Street 2:12000 STONE LAKE ROAD
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-0187
Mailing Address - Country:US
Mailing Address - Phone:575-759-3291
Mailing Address - Fax:575-759-3532
Practice Address - Street 1:12000 STONE LAKE ROAD
Practice Address - Street 2:JICARILLA SERVICE UNIT
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528
Practice Address - Country:US
Practice Address - Phone:575-759-3291
Practice Address - Fax:575-759-3532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO18451261QP0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMHSZ196OtherMEDICARE PART B
NM000K3526Medicaid
NM320057Medicare Oscar/Certification