Provider Demographics
NPI:1003087867
Name:LA CLINICA DE FAMILIA, INCORPORATED
Entity Type:Organization
Organization Name:LA CLINICA DE FAMILIA, INCORPORATED
Other - Org Name:HEALTY START PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SUZAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ DE GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-526-1105
Mailing Address - Street 1:570 W GRIGGS
Mailing Address - Street 2:HEALTHY START PROGRAM
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005
Mailing Address - Country:US
Mailing Address - Phone:575-524-0767
Mailing Address - Fax:575-528-5539
Practice Address - Street 1:570 W GRIGGS AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2604
Practice Address - Country:US
Practice Address - Phone:575-524-0767
Practice Address - Fax:575-528-5539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty