Healthcare Provider Details

I. General information

NPI: 1801075783
Provider Name (Legal Business Name): LOS ALAMOS PHYSICIAN PRACTICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3917 WEST RD #125
LOS ALAMOS NM
87544-2275
US

IV. Provider business mailing address

PO BOX 129
LOS ALAMOS NM
87544-0129
US

V. Phone/Fax

Practice location:
  • Phone: 505-661-3030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGIE MANGUM
Title or Position: DIRECTOR
Credential:
Phone: 505-521-5277