1366525537 NPI number — LA FAMILIA PRIMARY CARE P C

Table of content: DR. GLORIA AKUAMOAH BOATENG MD (NPI 1386141364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366525537 NPI number — LA FAMILIA PRIMARY CARE P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA FAMILIA PRIMARY CARE P C
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:
1366525537
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 HOSPITAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RATON
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87740-2002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-445-5563
Provider Business Mailing Address Fax Number:
575-445-5566

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
190 HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RATON
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87740-2002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-445-5563
Provider Business Practice Location Address Fax Number:
575-445-5566
Provider Enumeration Date:
10/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ZMILY
Authorized Official First Name:
MISBAH
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNERPRESIDENT
Authorized Official Telephone Number:
505-445-5563

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  96-165 , 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: 56903 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 607623110P . This is a "R.R. MEDICARE" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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