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)	3069	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	:	1699082644
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	:	575-355-2414
Fax Number	:	575-355-7894

Provider Business Practice Location Address
First Line	:	1001 SUMNER AVE
Second Line	:
City	:	FORT SUMNER
State	:	NM
Zip	:	88119-0349
Country	:	US
Telephone Number	:	575-355-4431
Fax Number	:	575-355-4432

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

Provider Enumeration Date	:	09/10/2010
Last Update Date	:	10/14/2025

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