MEDICARE: LA CLINICA DE FAMILIA, INCORPORATED

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)

General Provider Information

NPI Number	:	1215725122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA CLINICA DE FAMILIA, INCORPORATED

Provider Business Mailing Address
First Line	:	385 CALLE DE ALEGRA STE A
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88005-3423
Country	:	US
Telephone Number	:	575-526-1105
Fax Number	:	575-524-4266

Provider Business Practice Location Address
First Line	:	5700 MESA GRANDE DR
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-6017
Country	:	US
Telephone Number	:	575-526-1105
Fax Number	:	575-524-4266

Authorized Official
Title or Position	:	CEO
Name	:	VIRGIL MEDINA
Credential	:
Telephone Number	:	575-526-1105

Provider Enumeration Date	:	04/29/2025
Last Update Date	:	04/29/2025

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