Provider Demographics
NPI:1649593443
Name:MESCALERO INDIAN HOSPITAL
Entity Type:Organization
Organization Name:MESCALERO INDIAN HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DORLYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:575-464-4441
Mailing Address - Street 1:PO BOX 210
Mailing Address - Street 2:
Mailing Address - City:MESCALERO
Mailing Address - State:NM
Mailing Address - Zip Code:88340-0210
Mailing Address - Country:US
Mailing Address - Phone:575-464-4441
Mailing Address - Fax:575-464-4422
Practice Address - Street 1:318 ABALONE LOOP
Practice Address - Street 2:
Practice Address - City:MESCALERO
Practice Address - State:NM
Practice Address - Zip Code:88340
Practice Address - Country:US
Practice Address - Phone:575-464-4441
Practice Address - Fax:575-464-4422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR64860261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center