Provider Demographics
NPI:1689833170
Name:CROWNPOINT MOBILE CLINIC
Entity type:Organization
Organization Name:CROWNPOINT MOBILE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:ONEAL
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:
Practice Address - Street 1:HWY 371 NAVAJO JUNCTION ROUTE 9
Practice Address - Street 2:
Practice Address - City:CROWNPOINT
Practice Address - State:NM
Practice Address - Zip Code:87313-0358
Practice Address - Country:US
Practice Address - Phone:505-786-5291
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DHHS PHS NAIHS CROWNPOINT HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH8906Medicaid