Healthcare Provider Details

I. General information

NPI: 1053672485
Provider Name (Legal Business Name): ANGEL FIRE PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2012
Last Update Date: 06/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 A PIONEER ROAD
RED RIVER NM
87558-0000
US

IV. Provider business mailing address

707 PASEO DE PERALTA
SANTA FE NM
87501-1922
US

V. Phone/Fax

Practice location:
  • Phone: 575-754-1773
  • Fax: 505-989-3536
Mailing address:
  • Phone: 505-989-8707
  • Fax: 505-989-3536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LESA D FRAKER
Title or Position: PRESIDENT
Credential: MD
Phone: 505-989-8707