1962575712 NPI number — KOKOPELLI EAST WEST INTEGRATED FAMILY WALK-IN CLINIC, LLC

Table of content: (NPI 1962575712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962575712 NPI number — KOKOPELLI EAST WEST INTEGRATED FAMILY WALK-IN CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KOKOPELLI EAST WEST INTEGRATED FAMILY WALK-IN CLINIC, LLC
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:
1962575712
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6501 EAGLE ROCK AVE NE
Provider Second Line Business Mailing Address:
BUDG A6
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87113-2479
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-514-2900
Provider Business Mailing Address Fax Number:
505-797-2905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6501 EAGLE ROCK AVE NE
Provider Second Line Business Practice Location Address:
BUDG A6
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87113-2479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-514-2900
Provider Business Practice Location Address Fax Number:
505-797-5400
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PARK
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
DK
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
505-514-2900

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  866RX-1 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 2074 , 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)





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