MEDICARE: DE BACA FAMILY PRACTICE CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	321863	OTHER	NM	NGS ID

General Provider Information

NPI Number	:	1003855032
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DE BACA FAMILY PRACTICE CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 349
Second Line	:
City	:	FORT SUMNER
State	:	NM
Zip	:	88119-0349
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	546 N. TENTH ST
Second Line	:
City	:	FORT SUMNER
State	:	NM
Zip	:	88119
Country	:	US
Telephone Number	:	505-355-2414
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	LISA WALRAVEN
Credential	:
Telephone Number	:	575-355-2420

Provider Enumeration Date	:	06/05/2006
Last Update Date	:	10/14/2025

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