Provider Demographics
NPI:1265511299
Name:PUEBLO OF SAN FELIPE
Entity type:Organization
Organization Name:PUEBLO OF SAN FELIPE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PUEBLO OF SAN FELIPE TRIBAL ADMIN
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-867-3381
Mailing Address - Street 1:PO BOX 4339
Mailing Address - Street 2:
Mailing Address - City:SAN FELIPE
Mailing Address - State:NM
Mailing Address - Zip Code:87001
Mailing Address - Country:US
Mailing Address - Phone:505-867-9616
Mailing Address - Fax:505-771-9992
Practice Address - Street 1:3 CEDAR RD.
Practice Address - Street 2:
Practice Address - City:SAN FELIPE
Practice Address - State:NM
Practice Address - Zip Code:87001
Practice Address - Country:US
Practice Address - Phone:505-867-9616
Practice Address - Fax:505-771-9992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM99624371Medicaid
NM81271875Medicaid
NM81271875OtherPHARMACY