Healthcare Provider Details

I. General information

NPI: 1962743534
Provider Name (Legal Business Name): DE BACA FAMILY PRACTICE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2013
Last Update Date: 02/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

552 US HWY 54
SANTA ROSA NM
88435
US

IV. Provider business mailing address

PO BOX 349
FORT SUMNER NM
88119-0349
US

V. Phone/Fax

Practice location:
  • Phone: 575-472-2414
  • Fax: 575-472-2416
Mailing address:
  • Phone: 575-355-2414
  • Fax: 575-355-7894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: LISA WALRAVEN
Title or Position: CEO
Credential:
Phone: 575-355-2420