Provider Demographics
NPI:1083752919
Name:NORTH MAIN FAMILY HEALTH CENTER, PC
Entity Type:Organization
Organization Name:NORTH MAIN FAMILY HEALTH CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FAY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAFON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-525-3531
Mailing Address - Street 1:2611 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-1139
Mailing Address - Country:US
Mailing Address - Phone:505-525-3531
Mailing Address - Fax:505-525-3534
Practice Address - Street 1:2611 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-1139
Practice Address - Country:US
Practice Address - Phone:505-525-3531
Practice Address - Fax:505-525-3534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM8366207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM24968Medicaid
NMNM009103OtherBLUE CROSS BLUE SHIELD
NMD43208Medicare UPIN