De Baca Family Practice Clinic
Clinic/Center, Federally Qualified Health Center (FQHC) in Santa Rosa, NM. Organization (NPI-2).
NPI number1962743534
StatusActive
Last updated in NPPESFeb 1, 2018
Details
- NPI
- 1962743534
- Entity type
- Organization (NPI-2)
- Legal business name
- De Baca Family Practice Clinic
- Organization subpart
- Yes
- Enumeration date
- Mar 7, 2013
- Last updated
- Feb 1, 2018
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 261QF0400X | Clinic/Center, Federally Qualified Health Center (FQHC) | – | – | Yes |
| 261QD0000X | Clinic/Center, Dental | – | NM |
Other names
- Guadalupe Family Dental (Doing Business As)
Practice location
552 Us Hwy 54Santa Rosa, NM 88435
Phone 575-472-2414 · Fax 575-472-2416
Mailing address
Po Box 349Fort Sumner, NM 88119-0349
Phone 575-355-2414 · Fax 575-355-7894
Authorized official
Lisa Walraven
Ceo
5753552420
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