Organization
DE BACA FAMILY PRACTICE CLINIC
Active
Parent organization
DE BACA FAMILY PRACTICE CLINIC
Other names
De Baca Family Practice Clinic/Dental Clinic
Organization subpart
Yes
Provider details
NPI number
Legal business name
DE BACA FAMILY PRACTICE CLINIC
Authorized official
LISA WALRAVEN (CEO)
(575) 355-2420
Entity
Organization
Contact information
Practice address
678 AVENUE C, FORT SUMNER, NM 88119
(575) 355-2417
(575) 355-2418
Mailing address
PO BOX 349, FORT SUMNER, NM 88119-0349
(575) 355-2414
(575) 355-7894
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
—
—
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
—
Other
Enumeration date
01/10/2025
Last updated
10/14/2025
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