Provider Demographics
NPI:1518067669
Name:LA CASA DE BUENA SALUD INC
Entity Type:Organization
Organization Name:LA CASA DE BUENA SALUD INC
Other - Org Name:LA CASA FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SEFERINO
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-356-6695
Mailing Address - Street 1:PO BOX 843
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130
Mailing Address - Country:US
Mailing Address - Phone:505-356-6695
Mailing Address - Fax:505-356-5948
Practice Address - Street 1:1521 WEST 13TH STREET
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:505-769-0888
Practice Address - Fax:505-763-9154
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA CASA DE BUENA SALUD INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-25
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6415261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM46976Medicaid
NM321847Medicare Oscar/Certification
2371078Medicare ID - Type Unspecified