Provider Demographics
NPI:1558583005
Name:JAL HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:JAL HOSPITAL DISTRICT
Other - Org Name:JAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LIZA
Authorized Official - Middle Name:
Authorized Official - Last Name:TACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-395-3400
Mailing Address - Street 1:PO BOX Z
Mailing Address - Street 2:
Mailing Address - City:JAL
Mailing Address - State:NM
Mailing Address - Zip Code:88252-2525
Mailing Address - Country:US
Mailing Address - Phone:575-395-3400
Mailing Address - Fax:575-395-3355
Practice Address - Street 1:805 WEST KANSAS AVENUE
Practice Address - Street 2:
Practice Address - City:JAL
Practice Address - State:NM
Practice Address - Zip Code:88252
Practice Address - Country:US
Practice Address - Phone:575-395-3400
Practice Address - Fax:575-395-3355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6179261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM44479Medicaid