Organization
DE BACA FAMILY PRACTICE CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LISA WALRAVEN (CEO)
(575) 355-2420
Entity
Organization
Contact information
Practice address
546 N. TENTH ST, FORT SUMNER, NM 88119
(505) 355-2414
Mailing address
PO BOX 349, FORT SUMNER, NM 88119-0349
Taxonomy
Speciality
Code
Description
License number
State
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
321863
NGS ID
NM
Enumeration date
06/05/2006
Last updated
10/14/2025
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