Provider Demographics
NPI:1831274851
Name:SAN FELIPE HEALTH CLINIC
Entity type:Organization
Organization Name:SAN FELIPE HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LYON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-988-9821
Mailing Address - Street 1:PO BOX 4344
Mailing Address - Street 2:
Mailing Address - City:SAN FELIPE PB
Mailing Address - State:NM
Mailing Address - Zip Code:87001-4344
Mailing Address - Country:US
Mailing Address - Phone:505-867-6527
Mailing Address - Fax:505-867-6527
Practice Address - Street 1:CEDAR STREET
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:505-867-5485
Practice Address - Fax:505-867-6527
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SANTA FE INDIAN HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-26
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMH1232282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH1232Medicaid
NM320057Medicare Oscar/Certification
NMH1232Medicaid