Provider Demographics
NPI:1730485244
Name:LA CASA DE BUENA SALUD INC
Entity Type:Organization
Organization Name:LA CASA DE BUENA SALUD INC
Other - Org Name:LA CASA DENTAL SCHOOL CLINIC
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:575-356-6695
Mailing Address - Street 1:PO BOX 843
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-0843
Mailing Address - Country:US
Mailing Address - Phone:575-356-6695
Mailing Address - Fax:575-356-5948
Practice Address - Street 1:400 LOCKWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-8445
Practice Address - Country:US
Practice Address - Phone:575-769-5021
Practice Address - Fax:575-763-9154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)