Provider Demographics
NPI:1962575712
Name:KOKOPELLI EAST WEST INTEGRATED FAMILY WALK-IN CLINIC, LLC
Entity type:Organization
Organization Name:KOKOPELLI EAST WEST INTEGRATED FAMILY WALK-IN CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DK
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DOM
Authorized Official - Phone:505-514-2900
Mailing Address - Street 1:6501 EAGLE ROCK AVE NE
Mailing Address - Street 2:BUDG A6
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-2479
Mailing Address - Country:US
Mailing Address - Phone:505-514-2900
Mailing Address - Fax:505-797-2905
Practice Address - Street 1:6501 EAGLE ROCK AVE NE
Practice Address - Street 2:BUDG A6
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2479
Practice Address - Country:US
Practice Address - Phone:505-514-2900
Practice Address - Fax:505-797-5400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM866RX-1171100000X
NM2074225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM800521121Medicare ID - Type UnspecifiedMEDICARE GROUP ID NUMBER