Provider Demographics
NPI:1508838004
Name:LA CLINICA DE FAMILIA, INCORPORATED
Entity Type:Organization
Organization Name:LA CLINICA DE FAMILIA, INCORPORATED
Other - Org Name:LA CLINICA DE FAMILIA CHAPARRAL MEDICAL
Other - Org Type:Doing Business As
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 1:385 CALLE DE ALEGRA
Mailing Address - Street 2:BLDG. A
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3423
Mailing Address - Country:US
Mailing Address - Phone:575-526-1105
Mailing Address - Fax:575-524-4266
Practice Address - Street 1:510 E LISA DR
Practice Address - Street 2:
Practice Address - City:CHAPARRAL
Practice Address - State:NM
Practice Address - Zip Code:88081-7809
Practice Address - Country:US
Practice Address - Phone:575-824-0820
Practice Address - Fax:575-824-1021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM261QF0400X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMR8204Medicaid
NM321865Medicare PIN
NM2370905Medicare ID - Type Unspecified
NMR8204Medicaid