Basic Information
| Provider Information | |||||||||
| NPI: | 1740717743 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LA FAMILIA MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | LA FAMILIA MEDICAL CENTER HEALTH CARE FOR THE HOMELESS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5395 | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875025395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5056294714 | ||||||||
| FaxNumber: | 5059828440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1532 CERRILLOS RD STE B | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875053512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059881742 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2017 | ||||||||
| LastUpdateDate: | 11/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | JOLLY | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5059824599 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | FACHE | ||||||||
| NPICertificationDate: | 11/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | NM | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.