Healthcare Provider Details

I. General information

NPI: 1417440777
Provider Name (Legal Business Name): LAS CLINICAS DEL NORTE INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1797B ST. RD 502
SANTA FE NM
87506
US

IV. Provider business mailing address

PO BOX 237
EL RITO NM
87530-0237
US

V. Phone/Fax

Practice location:
  • Phone: 505-455-4026
  • Fax: 505-455-4038
Mailing address:
  • Phone: 505-455-4026
  • Fax: 575-581-0030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: ANDREA SANDOVAL
Title or Position: CEO
Credential: MBA
Phone: 575-581-4728