Provider Demographics
NPI:1699980391
Name:MESCALERO APACHE TRIBE
Entity type:Organization
Organization Name:MESCALERO APACHE TRIBE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTO
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:LANGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-464-9328
Mailing Address - Street 1:PO BOX 326
Mailing Address - Street 2:101 CENTRAL MESCALERO
Mailing Address - City:MESCALERO
Mailing Address - State:NM
Mailing Address - Zip Code:88340-0326
Mailing Address - Country:US
Mailing Address - Phone:505-464-9328
Mailing Address - Fax:505-464-8014
Practice Address - Street 1:101 CENTRAL MESCALERO DRIVE
Practice Address - Street 2:
Practice Address - City:MESCALERO
Practice Address - State:NM
Practice Address - Zip Code:88340-0326
Practice Address - Country:US
Practice Address - Phone:505-464-9328
Practice Address - Fax:505-464-8014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME8732Medicaid