Provider Demographics
NPI:1679716419
Name:PUEBLO OF ACOMA
Entity type:Organization
Organization Name:PUEBLO OF ACOMA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:A
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-991-7866
Mailing Address - Street 1:PO BOX 641880
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-7880
Mailing Address - Country:US
Mailing Address - Phone:402-991-7866
Mailing Address - Fax:505-552-9470
Practice Address - Street 1:74 INDIAN SERVICE
Practice Address - Street 2:ROUTE 32
Practice Address - City:ACOMA
Practice Address - State:NM
Practice Address - Zip Code:87034-0000
Practice Address - Country:US
Practice Address - Phone:505-552-7500
Practice Address - Fax:505-552-9470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-09
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM549803416L0300X, 3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54980OtherNM PRC