Provider Demographics
NPI:1184048423
Name:PUEBLO OF ISLETA ASSISTED LIVING FACILITY
Entity type:Organization
Organization Name:PUEBLO OF ISLETA ASSISTED LIVING FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GOVERNOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:505-869-3111
Mailing Address - Street 1:PO BOX 1270
Mailing Address - Street 2:
Mailing Address - City:ISLETA
Mailing Address - State:NM
Mailing Address - Zip Code:87022-1270
Mailing Address - Country:US
Mailing Address - Phone:505-869-3111
Mailing Address - Fax:505-869-7596
Practice Address - Street 1:1001 TRIBAL ROAD 40
Practice Address - Street 2:
Practice Address - City:ISLETA
Practice Address - State:NM
Practice Address - Zip Code:87022
Practice Address - Country:US
Practice Address - Phone:505-869-3111
Practice Address - Fax:505-869-7596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM311500000X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)