Jicarilla Apache Nation
Organization Active NPI End-Stage Renal Disease (ESRD) Treatment Clinic/Center · Dulce, NM
NPI 1881020089 · NPPES record last updated May 20, 2015
Key facts
- NPI
- 1881020089
- Entity type
- Organization (NPI type 2)
- Primary specialty
- End-Stage Renal Disease (ESRD) Treatment Clinic/Center 261QE0700X
- Legal business name
- JICARILLA APACHE NATION
- Practice address
- 450 N Mundo Dr.
Dulce, NM 87528 - Phone
- (575) 759-4206
- Fax
- (575) 759-4471
- NPI assigned
- Sep 19, 2013
- Organization subpart
- No
Authorized official
- Name
- Ty Vicenti
- Title
- President
- Phone
- (575) 759-4201
Affiliated clinicians 1
-
Tudor Ocneanu, MD
Medicare Care Compare: Dialysis facility
- Listed as
- Jicarilla Apache Nation Dialysis Treatment Center
- Overall star rating
- ★★☆☆☆ 2.0 of 5
- Ownership
- Profit
- Certified
- Mar 19, 2015
- Dialysis stations
- 12
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 32D2061646 | Jicarilla Apache Nation Dialysis Center | Certificate of waiver | Jul 1, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NM
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20140226000628 | NM | Part a Provider - End-Stage Renal Disease Facility (ESRD) | 4981834645 | Practice locations: Dulce, NM |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| End-Stage Renal Disease (ESRD) Treatment Clinic/Center | 261QE0700X | Yes |
Addresses
Primary practice location
450 N Mundo Dr.
Dulce, NM 87528
Mailing address
450 N Mundo Dr.
Dulce, NM 87528
Phone (575) 759-4206
Other names
- Jicarilla Apache Nation Dialysis Treatment Center
Other providers in Dulce, NM
- Diane P Holzem
- Indian Health Service- Jicarilla Service Unit
- Deanna S Iovine
- Jicarilla Apache Health Care Facility
- Jicarilla Apache Nation
- Jicarilla EMS
- Jicarilla Health Care Facility
- Jicarilla IHS Pharmacy
- Ray Morris Joe
- Joan E Kandel
All providers in Dulce, NM · End-Stage Renal Disease (ESRD) Treatment Clinic/Center in New Mexico
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 20, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.