De Baca Family Practice Clinic
Organization Active NPI Federally Qualified Health Center (FQHC) · Santa Rosa, NM
NPI 1962743534 · NPPES record last updated Feb 1, 2018
Key facts
- NPI
- 1962743534
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- DE BACA FAMILY PRACTICE CLINIC
- Practice address
- 552 US Hwy 54
Santa Rosa, NM 88435 - Phone
- (575) 472-2414
- Fax
- (575) 472-2416
- NPI assigned
- Mar 7, 2013
- Organization subpart
- Yes
- Parent organization (as reported)
- DE BACA FAMILY PRACTICE CLINIC
Authorized official
- Name
- Lisa Walraven
- Title
- Ceo
- Phone
- (575) 355-2420
Parent organization (reported in NPPES) 1
Other NPIs on the same Medicare enrollment 3
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NM
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
- Part of
- De Baca Family Practice
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dental Clinic/Center | 261QD0000X | NM | ||
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
552 US Hwy 54
Santa Rosa, NM 88435
Mailing address
PO Box 349
Fort Sumner, NM 88119-0349
Phone (575) 355-2414
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 84331534 | Medicaid | NM |
Other names
- Guadalupe Family Dental
Other providers in Santa Rosa, NM
- Collins Dental
- Raymond F Collins
- Estella L Cribbs
- Maria Crisostomo
- David Calkins, MD, LLC
- Desert Grace Physical Therapy LLC
- Abraham Diaz
- Dominic R Fernandez
- Victoria Flores
- Gloria E Gage
All providers in Santa Rosa, NM · Federally Qualified Health Center (FQHC) in New Mexico
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 1, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.