Healthcare Provider Details

I. General information

NPI: 1710384383
Provider Name (Legal Business Name): LA FAMILIA MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2014
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 ALTO ST
SANTA FE NM
87501-2406
US

IV. Provider business mailing address

1035 ALTO ST
SANTA FE NM
87501-2406
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-4425
  • Fax: 505-982-8440
Mailing address:
  • Phone: 505-982-4425
  • Fax: 505-982-1263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number6308
License Number StateNM

VIII. Authorized Official

Name: BRANDON VANESSA VAN PELT
Title or Position: CEO
Credential:
Phone: 505-982-4425