Provider Demographics
NPI:1548588643
Name:PUEBLO OF SANDIA
Entity type:Organization
Organization Name:PUEBLO OF SANDIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WASETA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-771-5174
Mailing Address - Street 1:481 SANDIA LOOP
Mailing Address - Street 2:
Mailing Address - City:BERNALILLO
Mailing Address - State:NM
Mailing Address - Zip Code:87004-7076
Mailing Address - Country:US
Mailing Address - Phone:505-867-4696
Mailing Address - Fax:505-867-4997
Practice Address - Street 1:203 SANDIA DAY SCHOOL ROAD
Practice Address - Street 2:
Practice Address - City:BERNALILLO
Practice Address - State:NM
Practice Address - Zip Code:87004-7076
Practice Address - Country:US
Practice Address - Phone:505-867-4696
Practice Address - Fax:505-771-5107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-13
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM35922079Medicaid