Provider Demographics
NPI:1194738328
Name:PUEBLO OF ISLETA
Entity type:Organization
Organization Name:PUEBLO OF ISLETA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-869-4094
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:01 SAGEBRUSH
Mailing Address - City:ISLETA
Mailing Address - State:NM
Mailing Address - Zip Code:87022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:01 SAGEBRUSH
Practice Address - Street 2:
Practice Address - City:ISLETA
Practice Address - State:NM
Practice Address - Zip Code:87022
Practice Address - Country:US
Practice Address - Phone:505-869-3200
Practice Address - Fax:505-869-4881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM30852081Medicaid
NM400521175Medicare ID - Type Unspecified