Provider Demographics
NPI:1902875594
Name:DHHS, PHS, NAIHS, GALLUP INDIAN MEDICAL CENTER
Entity Type:Organization
Organization Name:DHHS, PHS, NAIHS, GALLUP INDIAN MEDICAL CENTER
Other - Org Name:TOHATCHI HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACTING CEO
Authorized Official - Prefix:
Authorized Official - First Name:BENNIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:YAZZIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-722-1000
Mailing Address - Street 1:PO BOX 1337
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:505-722-1310
Practice Address - Street 1:007 CHOOSGAI DRIVE
Practice Address - Street 2:
Practice Address - City:TOHATCHI
Practice Address - State:NM
Practice Address - Zip Code:87325
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:505-722-1310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
9435261QP0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM06286518Medicaid
AZ061135Medicaid
AZ061135Medicaid
TX320061Medicare ID - Type Unspecified