Provider Demographics
NPI:1053672485
Name:ANGEL FIRE PRIMARY CARE
Entity Type:Organization
Organization Name:ANGEL FIRE PRIMARY CARE
Other - Org Name:RED RIVER PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LESA
Authorized Official - Middle Name:D
Authorized Official - Last Name:FRAKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-989-8707
Mailing Address - Street 1:707 PASEO DE PERALTA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1922
Mailing Address - Country:US
Mailing Address - Phone:505-989-8707
Mailing Address - Fax:505-989-3536
Practice Address - Street 1:200 A PIONEER ROAD
Practice Address - Street 2:
Practice Address - City:RED RIVER
Practice Address - State:NM
Practice Address - Zip Code:87558-0000
Practice Address - Country:US
Practice Address - Phone:575-754-1773
Practice Address - Fax:505-989-3536
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty