NPIMap

Organization Active NPI

De Baca Family Practice Clinic

Doing business as De Baca Family Practice Clinic/Mobile Unit

  • Federally Qualified Health Center (FQHC)
  • Fort Sumner, NM
National Provider Identifier
1114737483
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
Doing business as
De Baca Family Practice Clinic/Mobile Unit
Practice address
546 N 10TH Street
Fort Sumner, NM 88119
Phone
(575) 355-2414
Fax
(575) 355-7894
NPI assigned
Jan 9, 2025
Last updated
Oct 14, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
DE BACA FAMILY PRACTICE CLINICAs reported in NPPES

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 NU Primary

Addresses

Primary practice location

546 N 10TH Street
Fort Sumner, NM 88119

Mailing address

PO Box 349
Fort Sumner, NM 88119-0349
Phone (575) 355-2414

Other names 1

  • De Baca Family Practice Clinic/Mobile Unit Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NM

Enrollment records 1

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
This NPI is an additional NPI on the enrollment
Practice locations: Fort Sumner, NM

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
Part of
De Baca Family Practice

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 5

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": "1736380800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1760400000000",
    "number": "1114737483",
    "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",
            "telephone_number": "575-355-2414",
            "fax_number": "575-355-7894"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "546 N 10TH STREET",
            "city": "FORT SUMNER",
            "state": "NM",
            "postal_code": "88119",
            "telephone_number": "575-355-2414",
            "fax_number": "575-355-7894"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DE BACA FAMILY PRACTICE CLINIC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "DE BACA FAMILY PRACTICE CLINIC",
        "enumeration_date": "2025-01-09",
        "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": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "De Baca Family Practice Clinic/Mobile Unit",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fort Sumner, NM

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 14, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.