Provider Demographics
NPI:1558435990
Name:TOWN OF COCHITI LAKE
Entity Type:Organization
Organization Name:TOWN OF COCHITI LAKE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:GURULE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-697-0484
Mailing Address - Street 1:PO BOX 641880
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-7880
Mailing Address - Country:US
Mailing Address - Phone:402-572-4019
Mailing Address - Fax:888-506-4589
Practice Address - Street 1:6515C HOOCHANEETSA BLVD
Practice Address - Street 2:
Practice Address - City:COCHITI LAKE
Practice Address - State:NM
Practice Address - Zip Code:87083-6031
Practice Address - Country:US
Practice Address - Phone:505-465-2421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-18
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP4704Medicaid
NMNMB2315Medicare PIN