Provider Demographics
NPI:1790118446
Name:PUEBLO OF ZUNI
Entity Type:Organization
Organization Name:PUEBLO OF ZUNI
Other - Org Name:ZUNI TEEN HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARNELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUCATE-YEPA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-782-5719
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:505-782-5719
Mailing Address - Fax:
Practice Address - Street 1:02 TWIN BUTTES DR
Practice Address - Street 2:
Practice Address - City:ZUNI
Practice Address - State:NM
Practice Address - Zip Code:87327-0000
Practice Address - Country:US
Practice Address - Phone:505-782-5719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PUEBLO OF ZUNI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-16
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM11233371Medicaid