Basic Information
| Provider Information | |||||||||
| NPI: | 1710384383 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA FAMILIA MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ECHO CARE | ||||||||
| 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: | 11/26/2014 | ||||||||
| LastUpdateDate: | 11/26/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOLLY | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5059824425 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | FACHE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 6308 | NM | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.