Provider Demographics
NPI:1023366374
Name:NEW MEXICO FAMILY CLINIC LLC
Entity Type:Organization
Organization Name:NEW MEXICO FAMILY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRANCO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:505-881-4012
Mailing Address - Street 1:3908 JUAN TABO BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3971
Mailing Address - Country:US
Mailing Address - Phone:505-881-4012
Mailing Address - Fax:505-881-4898
Practice Address - Street 1:3908 JUAN TABO BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3971
Practice Address - Country:US
Practice Address - Phone:505-881-4012
Practice Address - Fax:505-881-4898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP00453363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM51107066Medicaid