Provider Demographics
NPI:1972528891
Name:WHITE SANDS FAMILY PRACTICE CLINIC, INC.
Entity type:Organization
Organization Name:WHITE SANDS FAMILY PRACTICE CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-488-2720
Mailing Address - Street 1:PO BOX 836
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88311-0836
Mailing Address - Country:US
Mailing Address - Phone:575-488-2720
Mailing Address - Fax:575-488-2721
Practice Address - Street 1:916 N WHITE SANDS BLVD
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6926
Practice Address - Country:US
Practice Address - Phone:575-488-2720
Practice Address - Fax:575-936-4077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM98-288207Q00000X
261Q00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM20559330Medicaid
NMNM007E60OtherBCBS GROUP NUMBER