Provider Demographics
NPI:1881011484
Name:PUEBLO OF LAGUNA
Entity Type:Organization
Organization Name:PUEBLO OF LAGUNA
Other - Org Name:COMMUNITY HEALTH & WELLNESS DEPT
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR HEALTH WELLNESS DEPARTMENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:RAMONA
Authorized Official - Middle Name:A
Authorized Official - Last Name:DILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-552-5741
Mailing Address - Street 1:3 SAN JOSE
Mailing Address - Street 2:
Mailing Address - City:LAGUNA
Mailing Address - State:NM
Mailing Address - Zip Code:87026-5026
Mailing Address - Country:US
Mailing Address - Phone:505-552-6652
Mailing Address - Fax:505-552-0605
Practice Address - Street 1:7 SAN JOSE ROAD
Practice Address - Street 2:
Practice Address - City:LAGUNA
Practice Address - State:NM
Practice Address - Zip Code:87026-0194
Practice Address - Country:US
Practice Address - Phone:505-552-6652
Practice Address - Fax:505-552-0605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-21
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 251K00000X, 251S00000X
NM01221825343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No251K00000XAgenciesPublic Health or Welfare
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM01221825Medicaid