Basic Information
| Provider Information | |||||||||
| NPI: | 1083687115 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LA CLINICA DE FAMILIA, INCORPORATED | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LA CLINICA DE FAMILIA SANTA TERESA SCHOOL BASE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 385 CALLE DE ALEGRA | ||||||||
| Address2: | BLDG. A | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880053423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755261105 | ||||||||
| FaxNumber: | 5755244266 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | SANTA TERESA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880089703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5758749338 | ||||||||
| FaxNumber: | 5758749338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2006 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEDINA | ||||||||
| AuthorizedOfficialFirstName: | VIRGIL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5755261105 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | NM | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 94479712 | 05 | NM | MEDICAID | 321946 | 01 | NM | MEDICARE | OTHER |