Provider Demographics
NPI:1124116736
Name:FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTA
Authorized Official - Middle Name:C
Authorized Official - Last Name:GALLEGOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-234-2008
Mailing Address - Street 1:201 N ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-4933
Mailing Address - Country:US
Mailing Address - Phone:505-234-2008
Mailing Address - Fax:505-885-1075
Practice Address - Street 1:201 N ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-4933
Practice Address - Country:US
Practice Address - Phone:505-234-2008
Practice Address - Fax:505-885-1075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001-33207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM21606714Medicaid
NM21606714Medicaid