Provider Demographics
NPI:1679007744
Name:EIGHT NORTHERN INDIAN PUEBLOS
Entity Type:Organization
Organization Name:EIGHT NORTHERN INDIAN PUEBLOS
Other - Org Name:NEW MOON LODGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:FORBES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:505-692-5034
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:327 EAGLE DRIVE
Mailing Address - City:OHKAY OWINGEH
Mailing Address - State:NM
Mailing Address - Zip Code:87566-0969
Mailing Address - Country:US
Mailing Address - Phone:575-751-7688
Mailing Address - Fax:
Practice Address - Street 1:579 WHITE SWAN RD
Practice Address - Street 2:327 EAGLE DRIVE
Practice Address - City:OHKAY OWINGEH
Practice Address - State:NM
Practice Address - Zip Code:87566
Practice Address - Country:US
Practice Address - Phone:505-852-2788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM28585810Medicaid