Provider Demographics
NPI:1780677039
Name:CIBOLA GENERAL HOSPITAL CORPORATION
Entity Type:Organization
Organization Name:CIBOLA GENERAL HOSPITAL CORPORATION
Other - Org Name:CIBOLA GENERAL HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROJAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-287-5202
Mailing Address - Street 1:1016 E ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2118
Mailing Address - Country:US
Mailing Address - Phone:505-287-5300
Mailing Address - Fax:505-287-5309
Practice Address - Street 1:1016 E ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2118
Practice Address - Country:US
Practice Address - Phone:505-287-5300
Practice Address - Fax:505-287-5309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6079282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000729Medicaid
NM321308OtherMEDICARE ID - UNSPECIFIED