LA CLINICA DE FAMILIA, INCORPORATED

Provider Demographics

• NPI: 1740286863
• Name: LA CLINICA DE FAMILIA, INCORPORATED
• Entity type: Organization
• Organization Name: LA CLINICA DE FAMILIA, INCORPORATED
• Authorized Official - Title/Position: CHEIF EXECUTIVE OFFICER
• Authorized Official - First Name: VIRGIL
• Authorized Official - Last Name: MEDINA
• 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: 385 CALLE DE ALEGRA
• Practice Address - Street 2: BLDG. A
• Practice Address - City: LAS CRUCES
• Practice Address - State: NM
• Practice Address - Zip Code: 88005-3423
• Practice Address - Country: US
• Practice Address - Phone: 575-526-1105
• Practice Address - Fax: 575-524-4266
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2005-06-23
• Last Update Date: 2021-05-13

Provider Licenses

State	License ID	Taxonomies
NM		261QF0400X
NM	96-175	207Q00000X
NM	A-1210-03	207Q00000X
NM	84-23	207Q00000X
NM	83-173	207Q00000X
NM	2003-0577	207Q00000X
NM	2001-38	207R00000X
NM	2002-0292	207Q00000X
NM	MD2004-0015	207R00000X
NM	2003-0543	207Q00000X
NM	A-1234-03	207Q00000X
NM	MD2003-0751	207Q00000X
NM	81-255	207V00000X
NM	A-1212-03	207Q00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207Q00000X	Allopathic & Osteopathic Physicians	Family Medicine		Group - Multi-Specialty
Yes	261QF0400X	Ambulatory Health Care Facilities	Clinic/Center	Federally Qualified Health Center (FQHC)	Group - Multi-Specialty
No	207R00000X	Allopathic & Osteopathic Physicians	Internal Medicine		Group - Multi-Specialty
No	207V00000X	Allopathic & Osteopathic Physicians	Obstetrics & Gynecology		Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
NM	72545	Medicaid
NM	2370905	Medicare PIN
NM	321865	Medicare ID - Type Unspecified
NM	321870	Medicare ID - Type Unspecified
NM	321812	Medicare ID - Type Unspecified
NM	321809	Medicare ID - Type Unspecified
NM	47753	Medicaid
NM	47552	Medicaid
NM	321810	Medicare ID - Type Unspecified
NM	78225	Medicaid
NM	321811	Medicare ID - Type Unspecified
NM	R8204	Medicaid
NM	R8197	Medicaid
NM	K6652	Medicaid
NM	74481	Medicaid
NM	48215	Medicaid
NM	48025	Medicaid