Provider Demographics
NPI:1689896284
Name:FIVE SANDOVAL INDIAN PUEBLOS, INC.
Entity Type:Organization
Organization Name:FIVE SANDOVAL INDIAN PUEBLOS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT-F.S.I.P IN
Authorized Official - Prefix:MS
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:PINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-867-3351
Mailing Address - Street 1:1043 HWY 313
Mailing Address - Street 2:
Mailing Address - City:BERNALILLO
Mailing Address - State:NM
Mailing Address - Zip Code:87004
Mailing Address - Country:US
Mailing Address - Phone:505-867-3351
Mailing Address - Fax:505-867-3514
Practice Address - Street 1:1043 HWY 313
Practice Address - Street 2:
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004
Practice Address - Country:US
Practice Address - Phone:505-867-3351
Practice Address - Fax:505-867-3514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM01728213006251S00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM96386002Medicaid