Basic Information
| Provider Information | |||||||||
| NPI: | 1467663278 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA CLINICA DE FAMILIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 575 S ALAMEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880052818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755286400 | ||||||||
| FaxNumber: | 5755244266 | ||||||||
| Practice Location | |||||||||
| Address1: | 385 CALLE DE ALEGRA | ||||||||
| Address2: | BLDG. A | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 88005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755261105 | ||||||||
| FaxNumber: | 5755244266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 09/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | MEDINA | ||||||||
| AuthorizedOfficialFirstName: | VIRGIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5755261105 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | PH00001798 | NM | Y | Suppliers | Pharmacy | Clinic Pharmacy |
No ID Information.