Provider Demographics
NPI:1790745974
Name:LA CLINICA DEL PUEBLO DE RIO ARRIBA
Entity Type:Organization
Organization Name:LA CLINICA DEL PUEBLO DE RIO ARRIBA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EMS DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:NREMT-P
Authorized Official - Phone:505-588-7252
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:TIERRA AMARILLA
Mailing Address - State:NM
Mailing Address - Zip Code:87575-0250
Mailing Address - Country:US
Mailing Address - Phone:505-588-7252
Mailing Address - Fax:505-588-7007
Practice Address - Street 1:HIGHWAY 84 COUNTY ROAD 324 #14
Practice Address - Street 2:
Practice Address - City:TIERRA AMARILLA
Practice Address - State:NM
Practice Address - Zip Code:87575
Practice Address - Country:US
Practice Address - Phone:505-588-7252
Practice Address - Fax:505-588-7007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2504636Medicare ID - Type Unspecified