Provider Demographics
NPI:1528714870
Name:NM SMALL TOWN FAMILY PRACTICE, LLC
Entity type:Organization
Organization Name:NM SMALL TOWN FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:R
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:505-366-3635
Mailing Address - Street 1:2000 LAM CT NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-7775
Mailing Address - Country:US
Mailing Address - Phone:575-621-3940
Mailing Address - Fax:505-392-3878
Practice Address - Street 1:4225 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1103
Practice Address - Country:US
Practice Address - Phone:505-366-3635
Practice Address - Fax:505-392-3878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care