Provider Demographics
NPI:1396964318
Name:KOKOPELLI EAST WEST INTEGRATED FAMILY HEALTHCARE, LLC
Entity type:Organization
Organization Name:KOKOPELLI EAST WEST INTEGRATED FAMILY HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DALKYU
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DOM
Authorized Official - Phone:505-514-2900
Mailing Address - Street 1:5900 FOREST HILLS DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4129
Mailing Address - Country:US
Mailing Address - Phone:505-514-2900
Mailing Address - Fax:
Practice Address - Street 1:2808 MESA RD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-7229
Practice Address - Country:US
Practice Address - Phone:505-994-0669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2033224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1929182795OtherGROUP NPI