Provider Demographics
NPI:1033977780
Name:BOSQUE CLINIC LLC
Entity type:Organization
Organization Name:BOSQUE CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:505-934-1071
Mailing Address - Street 1:1400 JACKIE RD SE STE 106
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1518
Mailing Address - Country:US
Mailing Address - Phone:505-934-1071
Mailing Address - Fax:505-451-0054
Practice Address - Street 1:1400 JACKIE RD SE STE 106
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1518
Practice Address - Country:US
Practice Address - Phone:505-934-1071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty