Provider Demographics
NPI:1124267968
Name:BOBBY COYNE LLC
Entity type:Organization
Organization Name:BOBBY COYNE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:COYNE
Authorized Official - Suffix:SR
Authorized Official - Credentials:LISW, LADAC
Authorized Official - Phone:505-661-9700
Mailing Address - Street 1:2164 43RD ST
Mailing Address - Street 2:STE C
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-1745
Mailing Address - Country:US
Mailing Address - Phone:505-661-9700
Mailing Address - Fax:505-663-0100
Practice Address - Street 1:127 EASTGATE DR
Practice Address - Street 2:STE 212 H
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-3300
Practice Address - Country:US
Practice Address - Phone:505-661-9700
Practice Address - Fax:505-663-0100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4758261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder