Provider Demographics
NPI:1578010070
Name:CANONCITO BAND OF NAVAJOS HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:CANONCITO BAND OF NAVAJOS HEALTH CENTER, INC.
Other - Org Name:CBN HEALTH CENTER, INC
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS OFFICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-908-2307
Mailing Address - Street 1:129 MEDICINE HORSE DRIVE
Mailing Address - Street 2:
Mailing Address - City:TOHAJIILEE
Mailing Address - State:NM
Mailing Address - Zip Code:87026
Mailing Address - Country:US
Mailing Address - Phone:505-908-2307
Mailing Address - Fax:505-908-2310
Practice Address - Street 1:129 MEDICINE HORSE DRIVE
Practice Address - Street 2:
Practice Address - City:TOHAJIILEE
Practice Address - State:NM
Practice Address - Zip Code:87026
Practice Address - Country:US
Practice Address - Phone:505-908-2307
Practice Address - Fax:505-908-2310
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CANONCITO BAND OF NAVAJOS HEALTH CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-01
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM91286018Medicaid