Provider Demographics
NPI:1396748661
Name:ZUNI HOME HEALTH CARE AGENCY
Entity type:Organization
Organization Name:ZUNI HOME HEALTH CARE AGENCY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GOV./PRES. BOARD OF DIRECTORS
Authorized Official - Prefix:
Authorized Official - First Name:ARLEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:QUETAWKI
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:505-782-5544
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:ZUNI
Mailing Address - State:NM
Mailing Address - Zip Code:87327-0339
Mailing Address - Country:US
Mailing Address - Phone:505-782-5544
Mailing Address - Fax:505-782-5546
Practice Address - Street 1:301 N ROUTE
Practice Address - Street 2:BLDG #52
Practice Address - City:ZUNI
Practice Address - State:NM
Practice Address - Zip Code:87327-0339
Practice Address - Country:US
Practice Address - Phone:505-782-5544
Practice Address - Fax:505-782-5546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6056251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMN1235Medicaid
NM32-7022Medicare ID - Type UnspecifiedPROVIDER NUMBER
NMN1235Medicaid