| Organization Name: | JICARILLA APACHE NATION |
| NPI Number: | 1881020089 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | TY VICENTI (PRESIDENT) |
| Mailing Address: | 450 N Mundo Dr. Dulce |
| State: | NM US |
| Postal Code: | 87528 |
| Phone Number: | 5757594206 |
| Fax Number: | 5757594471 |
| NPI Enumeration Date: | 09/19/2013 |
| NPI Last Update Date: | 05/20/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QE0700X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | End-Stage Renal Disease (ESRD) Treatment |
| Taxonomy Definition: | |