Provider Demographics
NPI:1841365558
Name:CANONCITO COMMUNITY CLINIC
Entity type:Organization
Organization Name:CANONCITO COMMUNITY CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ACL IHS CEO
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:FELIPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-552-5303
Mailing Address - Street 1:ACOMA CANONCITO LAGUNA INDIAN HOSPITAL
Mailing Address - Street 2:PO BOX 130
Mailing Address - City:SAN FIDEL
Mailing Address - State:NM
Mailing Address - Zip Code:87049
Mailing Address - Country:US
Mailing Address - Phone:505-552-5385
Mailing Address - Fax:505-552-5490
Practice Address - Street 1:EXIT #131 OFF I 40 6 MILES NORTH
Practice Address - Street 2:
Practice Address - City:SAN FIDEL
Practice Address - State:NM
Practice Address - Zip Code:87049-0130
Practice Address - Country:US
Practice Address - Phone:505-552-5385
Practice Address - Fax:505-552-5828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM320070OtherRAILROAD MEDICARE
NMHSZ022OtherRAILROAD MEDICARE
NML9815Medicaid
NML9815Medicaid
NM320070OtherRAILROAD MEDICARE