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)		NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396718631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA CLINICA DE FAMILIA, INCORPORATED

Provider Business Mailing Address
First Line	:	385 CALLE DE ALEGRA
Second Line	:	BLDG. A
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	:	18420 S HIGHWAY 28
Second Line	:
City	:	LA MESA
State	:	NM
Zip	:	88044-9605
Country	:	US
Telephone Number	:	575-233-3830
Fax Number	:	575-233-4542

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

Provider Enumeration Date	:	02/08/2006
Last Update Date	:	05/13/2021

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