Provider Demographics
NPI:1720256134
Name:LAS CLINICAS DEL NORTE INCORPORATED
Entity Type:Organization
Organization Name:LAS CLINICAS DEL NORTE INCORPORATED
Other - Org Name:MESA VISTA SCHOOL BASED HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:R
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-581-4728
Mailing Address - Street 1:PO BOX 237
Mailing Address - Street 2:571 ST RD BLDG 28
Mailing Address - City:EL RITO
Mailing Address - State:NM
Mailing Address - Zip Code:87530-0237
Mailing Address - Country:US
Mailing Address - Phone:575-581-4728
Mailing Address - Fax:575-581-0030
Practice Address - Street 1:HWY 285 JUNCTION 111
Practice Address - Street 2:
Practice Address - City:OJO CALIENTE
Practice Address - State:NM
Practice Address - Zip Code:87549
Practice Address - Country:US
Practice Address - Phone:505-583-2401
Practice Address - Fax:575-581-0030
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAS CLINICAS DEL NORTE INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-19
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM69222070Medicaid