Provider Demographics
NPI:1477922409
Name:LA FAMILIA MEDICAL CENTER
Entity Type:Organization
Organization Name:LA FAMILIA MEDICAL CENTER
Other - Org Name:LA FAMILIA MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN PELT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-424-5683
Mailing Address - Street 1:1035 ALTO ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2406
Mailing Address - Country:US
Mailing Address - Phone:505-982-4425
Mailing Address - Fax:505-982-8440
Practice Address - Street 1:1035 ALTO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-2406
Practice Address - Country:US
Practice Address - Phone:505-955-0322
Practice Address - Fax:505-212-4084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-21
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM90806565Medicaid
NM2371876Medicare PIN