Provider Demographics
NPI:1003855032
Name:DE BACA FAMILY PRACTICE CLINIC
Entity Type:Organization
Organization Name:DE BACA FAMILY PRACTICE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALRAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-355-2414
Mailing Address - Street 1:PO BOX 349
Mailing Address - Street 2:
Mailing Address - City:FORT SUMNER
Mailing Address - State:NM
Mailing Address - Zip Code:88119-0349
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:546 N. TENTH ST
Practice Address - Street 2:
Practice Address - City:FORT SUMNER
Practice Address - State:NM
Practice Address - Zip Code:88119
Practice Address - Country:US
Practice Address - Phone:505-355-2414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM321863OtherNGS ID
NM321863Medicare Oscar/Certification
NM4817190001Medicare NSC
NM900521008Medicare PIN