Organization
DE BACA FAMILY PRACTICE CLINIC
Active
Parent organization
DE BACA FAMILY PRACTICE CLINIC
Other names
Guadalupe Family Dental
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
552 US HWY 54, SANTA ROSA, NM 88435
(575) 472-2414
(575) 472-2416
Mailing address
PO BOX 349, FORT SUMNER, NM 88119-0349
(575) 355-2414
(575) 355-7894
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
—
NM
261QF0400X
Federally Qualified Health Center (FQHC)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
84331534
—
NM
Enumeration date
03/07/2013
Last updated
02/01/2018
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