Healthcare Provider Details

I. General information

NPI: 1023366374
Provider Name (Legal Business Name): NEW MEXICO FAMILY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3908 JUAN TABO BLVD NE
ALBUQUERQUE NM
87111-3971
US

IV. Provider business mailing address

3908 JUAN TABO BLVD NE
ALBUQUERQUE NM
87111-3971
US

V. Phone/Fax

Practice location:
  • Phone: 505-881-4012
  • Fax: 505-881-4898
Mailing address:
  • Phone: 505-881-4012
  • Fax: 505-881-4898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP00453
License Number StateNM

VIII. Authorized Official

Name: CARLA FRANCO
Title or Position: REGISTERED AGENT
Credential: FNP-BC
Phone: 505-881-4012