1245248830 NPI number — LOS ALAMOS PEDIATRIC CLINIC

Table of content: (NPI 1245248830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245248830 NPI number — LOS ALAMOS PEDIATRIC CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOS ALAMOS PEDIATRIC CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245248830
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3917 WEST ROAD
Provider Second Line Business Mailing Address:
SUITE 136
Provider Business Mailing Address City Name:
LOS ALAMOS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-662-9620
Provider Business Mailing Address Fax Number:
505-662-0024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3917 WEST ROAD
Provider Second Line Business Practice Location Address:
SUITE 136
Provider Business Practice Location Address City Name:
LOS ALAMOS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-662-9620
Provider Business Practice Location Address Fax Number:
505-662-0024
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KROHN
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
509-662-9620

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  79195 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10003513 . This is a "LOVELACE HEALTH" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 11783 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6693 . This is a "HMA NAVAJO NATION" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: PROVP13573 . This is a "MOLINA HEALTHCARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NM011552 . This is a "BCBS" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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