Provider Demographics
NPI:1881020089
Name:JICARILLA APACHE NATION
Entity Type:Organization
Organization Name:JICARILLA APACHE NATION
Other - Org Name:JICARILLA APACHE NATION DIALYSIS TREATMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TY
Authorized Official - Middle Name:
Authorized Official - Last Name:VICENTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-759-4201
Mailing Address - Street 1:450 N MUNDO DR.
Mailing Address - Street 2:
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528
Mailing Address - Country:US
Mailing Address - Phone:575-759-4206
Mailing Address - Fax:575-759-4471
Practice Address - Street 1:450 N MUNDO DR.
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528
Practice Address - Country:US
Practice Address - Phone:575-759-4206
Practice Address - Fax:575-759-4471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment