NPIMap

Organization Active NPI

De Baca Family Practice Clinic

  • Federally Qualified Health Center (FQHC)
  • Fort Sumner, NM
National Provider Identifier
1003855032
Registry record updated Oct 14, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
DE BACA FAMILY PRACTICE CLINIC
Practice address
546 N. Tenth St
Fort Sumner, NM 88119
Phone
(505) 355-2414
NPI assigned
Jun 5, 2006
Last updated
Oct 14, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 14, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Lisa Walraven
Title
Ceo
Phone
(575) 355-2420

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

546 N. Tenth St
Fort Sumner, NM 88119

Mailing address

PO Box 349
Fort Sumner, NM 88119-0349

Other identifiers 1

IdentifierTypeStateIssuer
321863OtherNMNGS ID

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NM2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040122000409 NM Part B Supplier - Clinic/Group Practice 6406758358 Receives reassigned benefits from 5 practitioners
3 other NPIs on this enrollment
Practice locations: Fort Sumner, NM
O20060621000067 NM Part A Provider - Federally Qualified Health Center (FQHC) 6406758358 Practice locations: Fort Sumner, NM

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1003855032. Details of each certification follow.

Federally qualified health center certification: CCN 321863

Legal name
DE BACA FAMILY PRACTICE CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Dec 23, 1996
Last certification
Dec 23, 1996
Ownership / control type
Non-profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 10, 2003 in NM
Enrollment address
546 N 10TH Street
Fort Sumner, NM 88119-0349

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

1600 Wallace Blvd
Amarillo, TX 79106
Phone (806) 212-2000

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/DGGJCD

Ownership & related parties

All disclosed owners & managing parties 11

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Joe Steele Individual Corporate Director Nov 1, 2011
Vincent Stallard Individual Corporate Director Nov 1, 2010
Jack D Vick Individual Corporate DirectorMedical Director Jan 5, 2009
Lisa D Walraven Individual W-2 Managing EmployeeCeo Jul 1, 2014 100%
Operational/Managerial ControlCeo Jul 1, 2014 100%
Larry Williamson Individual Corporate Director Nov 1, 2016
Robert Jack Individual Corporate Director Nov 1, 2018
Susan Vick Individual Corporate DirectorCfo Nov 1, 2010
Marie Dickerman Individual Corporate Director Nov 1, 2015
Charlie West Individual Corporate OfficerSecretary Board of Directors Nov 1, 2010
Beverly Overton Individual Corporate Director Nov 1, 2010
John Fallon Individual Corporate OfficerVice President Board of Directors Nov 1, 2016

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
De Baca Family Practice Clinic/School SiteFort Sumner, NM, CCN 321958 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jan 1, 2006
Jan 1, 2006

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

  • De Baca Family Practice Clinic

    dba De Baca Family Practice Clinic/School Site

    • Federally Qualified Health Center (FQHC)
    • Fort Sumner, NM
    • NPI 1699082644

    5% Or Greater Direct Ownership Interest, Operational/Managerial Control

    CMS ownership

Subparts reporting this organization as parent 4

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149465600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1760400000000",
    "number": "1003855032",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 349",
            "city": "FORT SUMNER",
            "state": "NM",
            "postal_code": "881190349"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "546 N. TENTH ST",
            "city": "FORT SUMNER",
            "state": "NM",
            "postal_code": "88119",
            "telephone_number": "505-355-2414"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DE BACA FAMILY PRACTICE CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-05",
        "last_updated": "2025-10-14",
        "certification_date": "2025-10-14",
        "status": "A",
        "authorized_official_last_name": "WALRAVEN",
        "authorized_official_first_name": "LISA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "575-355-2420"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NGS ID",
            "identifier": "321863",
            "state": "NM"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Sumner, NM

Sources for this page

Verify at the official NPI Registry.