Provider Demographics
NPI:1780686907
Name:ZUNI MEDICAL SUPPLY ENTERPRISE
Entity Type:Organization
Organization Name:ZUNI MEDICAL SUPPLY ENTERPRISE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GOV./PRES. BOARD OF DIRECTORS
Authorized Official - Prefix:
Authorized Official - First Name:ARLEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:QUETAWKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-782-2434
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:ZUNI
Mailing Address - State:NM
Mailing Address - Zip Code:87327-0339
Mailing Address - Country:US
Mailing Address - Phone:505-782-2434
Mailing Address - Fax:505-782-2457
Practice Address - Street 1:BUILDING 52 ROUTE 301 NORTH
Practice Address - Street 2:
Practice Address - City:ZUNI
Practice Address - State:NM
Practice Address - Zip Code:87327-0339
Practice Address - Country:US
Practice Address - Phone:505-782-2434
Practice Address - Fax:505-782-2457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM01103332B00000X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMT1046Medicaid
NMT1046Medicaid