Provider Demographics
NPI:1679516702
Name:THOREAU CLINIC
Entity type:Organization
Organization Name:THOREAU CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANSLEM
Authorized Official - Middle Name:
Authorized Official - Last Name:ROANHORSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-786-5291
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:
Mailing Address - City:CROWNPOINT
Mailing Address - State:NM
Mailing Address - Zip Code:87313-0358
Mailing Address - Country:US
Mailing Address - Phone:505-786-5291
Mailing Address - Fax:505-786-6440
Practice Address - Street 1:3 NAVARRE STREET
Practice Address - Street 2:
Practice Address - City:THOREAU
Practice Address - State:NM
Practice Address - Zip Code:87323
Practice Address - Country:US
Practice Address - Phone:505-862-8250
Practice Address - Fax:505-862-8909
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DHHS PHS NAIHS CROWNPOINT HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-14
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR2903Medicaid
NMHSZ145OtherMEDICARE GROUP PTAN
NMR2903Medicaid