Provider Demographics
NPI:1336659077
Name:KEWA PUEBLO HEALTH CORPORATION
Entity Type:Organization
Organization Name:KEWA PUEBLO HEALTH CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFIICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SURAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:AGBOKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-465-3060
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:SANTO DOMINGO PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87052-0340
Mailing Address - Country:US
Mailing Address - Phone:505-465-3060
Mailing Address - Fax:505-465-1155
Practice Address - Street 1:85 WEST HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:SANTO DOMINGO PUEBLO
Practice Address - State:NM
Practice Address - Zip Code:87052
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KEWA PUEBLO HEALTH CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM82674060Medicaid