Provider Demographics
NPI:1609913961
Name:PUEBLO OF JEMEZ
Entity Type:Organization
Organization Name:PUEBLO OF JEMEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NOHEMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-834-3187
Mailing Address - Street 1:4535 HIGHWAY 4
Mailing Address - Street 2:
Mailing Address - City:JEMEZ PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87024-0219
Mailing Address - Country:US
Mailing Address - Phone:575-834-7359
Mailing Address - Fax:
Practice Address - Street 1:4535 HIGHWAY 4
Practice Address - Street 2:
Practice Address - City:JEMEZ PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87024-0219
Practice Address - Country:US
Practice Address - Phone:575-834-7359
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1240463416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR3638Medicaid
NMR3638Medicaid