Provider Demographics
NPI:1932267259
Name:PUEBLO OF LAGUNA
Entity type:Organization
Organization Name:PUEBLO OF LAGUNA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MILES
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-552-5779
Mailing Address - Street 1:PO BOX 179
Mailing Address - Street 2:
Mailing Address - City:LAGUNA
Mailing Address - State:NM
Mailing Address - Zip Code:87026-0179
Mailing Address - Country:US
Mailing Address - Phone:505-552-5796
Mailing Address - Fax:505-552-6941
Practice Address - Street 1:5 BLUE STAR LOOP
Practice Address - Street 2:
Practice Address - City:PARAJE
Practice Address - State:NM
Practice Address - Zip Code:87007
Practice Address - Country:US
Practice Address - Phone:505-552-1102
Practice Address - Fax:505-552-6577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM541943416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10014280OtherLOVELACE SALUD
NM00NM00RC01OtherBCBS OF NM
AZ964678Medicaid
NM201078520OtherPRESBYTERIAN HEALTH PLAN
NMR0225Medicaid
NM00NM00RC01OtherBCBS OF NM
NMP00189254Medicare ID - Type UnspecifiedRAILROAD MEDICARE