Basic Information
Provider Information
NPI: 1255711255
EntityType: 2
ReplacementNPI:  
OrganizationName: LA CLINICA DE FAMILIA, INCORPORATED
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
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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: 575 S ALAMEDA BLVD
Address2:  
City: LAS CRUCES
State: NM
PostalCode: 880052818
CountryCode: US
TelephoneNumber: 5756472891
FaxNumber: 5756742901
Other Information
ProviderEnumerationDate: 06/04/2015
LastUpdateDate: 03/26/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: MEDINA
AuthorizedOfficialFirstName: VIRGIL
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CEO
AuthorizedOfficialTelephone: 5755261105
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 03/26/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
253J00000X  Y AgenciesFoster Care Agency 

ID Information
IDTypeStateIssuerDescription
8427455705NM MEDICAID


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