Provider Demographics
NPI:1962743534
Name:DE BACA FAMILY PRACTICE CLINIC
Entity type:Organization
Organization Name:DE BACA FAMILY PRACTICE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALRAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-355-2420
Mailing Address - Street 1:PO BOX 349
Mailing Address - Street 2:
Mailing Address - City:FORT SUMNER
Mailing Address - State:NM
Mailing Address - Zip Code:88119-0349
Mailing Address - Country:US
Mailing Address - Phone:575-355-2414
Mailing Address - Fax:575-355-7894
Practice Address - Street 1:552 US HWY 54
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:NM
Practice Address - Zip Code:88435
Practice Address - Country:US
Practice Address - Phone:575-472-2414
Practice Address - Fax:575-472-2416
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DE BACA FAMILY PRACTICE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-07
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM261QD0000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM84331534Medicaid