Healthcare Provider Details

I. General information

NPI: 1962575712
Provider Name (Legal Business Name): KOKOPELLI EAST WEST INTEGRATED FAMILY WALK-IN CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 EAGLE ROCK AVE NE BUDG A6
ALBUQUERQUE NM
87113-2479
US

IV. Provider business mailing address

6501 EAGLE ROCK AVE NE BUDG A6
ALBUQUERQUE NM
87113-2479
US

V. Phone/Fax

Practice location:
  • Phone: 505-514-2900
  • Fax: 505-797-5400
Mailing address:
  • Phone: 505-514-2900
  • Fax: 505-797-2905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number866RX-1
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2074
License Number StateNM

VIII. Authorized Official

Name: DR. JAMES DK PARK
Title or Position: OFFICE MANAGER
Credential: DOM
Phone: 505-514-2900