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General NPI Number Information
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NPI Number | 1699748921
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Entity Type | Organization
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Legal Business Name | LA CLINICA DE FAMILIA, INCORPORATED
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Dates
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Enumeration Date | 02/08/2006
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Last Update Date | 09/18/2025
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Provider Practice Location Address
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Address Line | 855 ANTHONY DR
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City | ANTHONY
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State | NM
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Zip | 88021-9325
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Country | US
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Telephone | 575-882-5706
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Fax | 575-882-2909
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Provider Business Mailing Address
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Address Line | 385 CALLE DE ALEGRA BLDG. A
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City | LAS CRUCES
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State | NM
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Zip | 88005-3423
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Country | US
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Telephone | 575-526-1105
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Fax | 575-524-4266
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | VIRGIL MEDINA
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Credential |
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Telephone | 575-526-1105
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number |
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License Number State | NM
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