Provider Demographics
NPI:1639553928
Name:LA CLINICA DE FAMILIA, INCORPORATED
Entity Type:Organization
Organization Name:LA CLINICA DE FAMILIA, INCORPORATED
Other - Org Name:CENTENNIAL SCHOOL BASE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
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 1:1950 SONOMA RANCH BLVD.
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011
Practice Address - Country:US
Practice Address - Phone:575-525-4811
Practice Address - Fax:575-524-4266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty