NPIMap

Organization Active NPI

De Baca Family Practice Clinic

Doing business as De Baca Family Practice Clinic/School Site

  • Federally Qualified Health Center (FQHC)
  • Fort Sumner, NM
National Provider Identifier
1699082644
Registry record updated Oct 14, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
3069 Issued in NM
Legal business name
DE BACA FAMILY PRACTICE CLINIC
Doing business as
De Baca Family Practice Clinic/School Site
Practice address
1001 Sumner Ave
Fort Sumner, NM 88119-0349
Phone
(575) 355-4431
Fax
(575) 355-4432
NPI assigned
Sep 10, 2010
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 3069 NM Primary

Addresses

Primary practice location

1001 Sumner Ave
Fort Sumner, NM 88119-0349

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
38003384MedicaidNM

Other names 1

  • De Baca Family Practice Clinic/School Site Doing business as

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
This NPI is an additional NPI on the enrollment
Practice locations: Fort Sumner, NM
O20180212002394 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 1699082644. Details of each certification follow.

Federally qualified health center certification: CCN 321958

Legal name
DE BACA FAMILY PRACTICE CLINIC
Doing business as
DE BACA FAMILY PRACTICE CLINIC/SCHOOL SITE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 12, 2018
Last certification
Feb 12, 2018
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 6, 2001 in NM
Enrollment address
1001 Sumner Ave
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
Tax ID family
De Baca Family Practice2 organizations share this tax ID, including this one
Part of
De Baca Family Practice

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Lisa D Walraven Individual Contracted Managing EmployeeCeo Jul 1, 2014 100%
Corporate OfficerCeo Jul 1, 2014 100%
Operational/Managerial Control Jul 1, 2014 100%
De Baca Family Practice Clinic Organization, Fort Sumner, NM Corporation, Non-profit 5% Or Greater Direct Ownership Interest Jan 1, 2006 100%
Operational/Managerial Control Jan 1, 2006 100%

Owners & managing parties with NPI records 1

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

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 3

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": "1284076800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1760400000000",
    "number": "1699082644",
    "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": "1001 SUMNER AVE",
            "city": "FORT SUMNER",
            "state": "NM",
            "postal_code": "881190349",
            "telephone_number": "575-355-4431",
            "fax_number": "575-355-4432"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DE BACA FAMILY PRACTICE CLINIC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "DE BACA FAMILY PRACTICE CLINIC",
        "enumeration_date": "2010-09-10",
        "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": "NM",
            "license": "3069",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "38003384",
            "state": "NM"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "De Baca Family Practice Clinic/School Site",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fort Sumner, NM

Sources for this page

Verify at the official NPI Registry.