Provider Demographics
NPI:1467663278
Name:LA CLINICA DE FAMILIA
Entity Type:Organization
Organization Name:LA CLINICA DE FAMILIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGIL
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-526-1105
Mailing Address - Street 1:575 S ALAMEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-2818
Mailing Address - Country:US
Mailing Address - Phone:575-528-6400
Mailing Address - Fax:575-524-4266
Practice Address - Street 1:385 CALLE DE ALEGRA
Practice Address - Street 2:BLDG. A
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005
Practice Address - Country:US
Practice Address - Phone:575-526-1105
Practice Address - Fax:575-524-4266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPH000017983336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy