Provider Demographics
NPI:1245248830
Name:LOS ALAMOS PEDIATRIC CLINIC
Entity type:Organization
Organization Name:LOS ALAMOS PEDIATRIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:KROHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-662-9620
Mailing Address - Street 1:3917 WEST ROAD
Mailing Address - Street 2:SUITE 136
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544
Mailing Address - Country:US
Mailing Address - Phone:505-662-9620
Mailing Address - Fax:505-662-0024
Practice Address - Street 1:3917 WEST ROAD
Practice Address - Street 2:SUITE 136
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544
Practice Address - Country:US
Practice Address - Phone:505-662-9620
Practice Address - Fax:505-662-0024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM79195208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10003513OtherLOVELACE HEALTH
NM11783Medicaid
NM6693OtherHMA NAVAJO NATION
NMPROVP13573OtherMOLINA HEALTHCARE
NMNM011552OtherBCBS
NMPROVP13573OtherMOLINA HEALTHCARE