Provider Demographics
NPI:1558668434
Name:CIRCLE OF LIFE
Entity Type:Organization
Organization Name:CIRCLE OF LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-852-1977
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87566-0969
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1102A PASEO DE ONATE
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532
Practice Address - Country:US
Practice Address - Phone:505-852-1377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EIGHT NORTHERN INDIAN PUEBLOS COUNCIL INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-02-11
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-07620251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health