Provider Demographics
NPI:1083834436
Name:LAS CLINICAS DEL NORTE INCORPORATED
Entity Type:Organization
Organization Name:LAS CLINICAS DEL NORTE INCORPORATED
Other - Org Name:LAS CLINICAS DEL NORTE ABIQUIU CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:R
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-581-4728
Mailing Address - Street 1:PO BOX 237
Mailing Address - Street 2:
Mailing Address - City:EL RITO
Mailing Address - State:NM
Mailing Address - Zip Code:87530-0237
Mailing Address - Country:US
Mailing Address - Phone:575-581-4728
Mailing Address - Fax:575-581-4731
Practice Address - Street 1:21192 HIGHWAY 84
Practice Address - Street 2:
Practice Address - City:ABIQUIU
Practice Address - State:NM
Practice Address - Zip Code:87510
Practice Address - Country:US
Practice Address - Phone:505-685-4479
Practice Address - Fax:505-685-4532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
3209613OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NM62988Medicaid
321873Medicare Oscar/Certification