Healthcare Provider Details

I. General information

NPI: 1245248830
Provider Name (Legal Business Name): LOS ALAMOS PEDIATRIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3917 WEST ROAD SUITE 136
LOS ALAMOS NM
87544
US

IV. Provider business mailing address

3917 WEST ROAD SUITE 136
LOS ALAMOS NM
87544
US

V. Phone/Fax

Practice location:
  • Phone: 505-662-9620
  • Fax: 505-662-0024
Mailing address:
  • Phone: 505-662-9620
  • Fax: 505-662-0024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number79195
License Number StateNM

VIII. Authorized Official

Name: DR. JACQUELINE ANNE KROHN
Title or Position: PRESIDENT
Credential: MD
Phone: 509-662-9620