Basic Information
| Provider Information | |||||||||
| NPI: | 1477922409 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LA FAMILIA MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LA FAMILIA MEDICAL CENTER PHARMACY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1035 ALTO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875012406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059824425 | ||||||||
| FaxNumber: | 5059828440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1035 ALTO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875012406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059824425 | ||||||||
| FaxNumber: | 5059828440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2015 | ||||||||
| LastUpdateDate: | 11/16/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOLLY | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5059824599 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LA FAMILIA MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | FACHE | ||||||||
| NPICertificationDate: | 11/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | N | Suppliers | Pharmacy | Clinic Pharmacy | 261QF0400X | 6308 | NM | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | F8002 | 05 | NM | MEDICAID |