Healthcare Provider Details

I. General information

NPI: 1124267968
Provider Name (Legal Business Name): BOBBY COYNE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2009
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 EASTGATE DR STE 212 H
LOS ALAMOS NM
87544-3300
US

IV. Provider business mailing address

2164 43RD ST STE C
LOS ALAMOS NM
87544-1745
US

V. Phone/Fax

Practice location:
  • Phone: 505-661-9700
  • Fax: 505-663-0100
Mailing address:
  • Phone: 505-661-9700
  • Fax: 505-663-0100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number4758
License Number StateNM

VIII. Authorized Official

Name: MR. ROBERT JOSEPH COYNE SR.
Title or Position: CLINICAL DIRECTOR
Credential: LISW, LADAC
Phone: 505-661-9700