Provider Demographics
NPI:1164851382
Name:DJAA TLHENAI MEDICINE LODGE
Entity type:Organization
Organization Name:DJAA TLHENAI MEDICINE LODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:OATZINU
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEELAKEE
Authorized Official - Suffix:
Authorized Official - Credentials:IAMP
Authorized Official - Phone:505-819-3403
Mailing Address - Street 1:POB 4682
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87196
Mailing Address - Country:US
Mailing Address - Phone:505-819-3403
Mailing Address - Fax:
Practice Address - Street 1:111 CARLISLE BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-1427
Practice Address - Country:US
Practice Address - Phone:505-819-3403
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LI PA HENNE TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-07
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM12-00116271174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty