Provider Demographics
NPI:1801100466
Name:BERNALILLO FAMILY HEALTH CLINIC, LLC
Entity type:Organization
Organization Name:BERNALILLO FAMILY HEALTH CLINIC, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:DELUISA
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:505-331-0295
Mailing Address - Street 1:PO BOX 25744
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-0744
Mailing Address - Country:US
Mailing Address - Phone:505-508-0197
Mailing Address - Fax:505-508-0465
Practice Address - Street 1:200 OAK ST NE
Practice Address - Street 2:SUITE 2
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4740
Practice Address - Country:US
Practice Address - Phone:505-508-0197
Practice Address - Fax:505-508-0465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-05
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QU0200X, 291U00000X
NMCNP-01518261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ7732Medicaid
NM21253790Medicaid
NM77304853Medicaid
NM10326855Medicaid
NM37805771Medicaid
NM10326855Medicaid
NM1568786085Medicare NSC
NMNMAAA0559Medicare PIN
NM77304853Medicaid