DE BACA FAMILY PRACTICE CLINIC; NPI #1699082644

Contact Information

DE BACA FAMILY PRACTICE CLINIC

1001 SUMNER AVE
FORT SUMNER, NM 88119-0349

Phone: 575-355-4431
Fax: 575-355-4432
Website:

	Specialty	Taxonomy Code	Specialty Code	Provider Type
	Federally Qualified Health Center (FQHC)	261QF0400X	B4[14]	Federally Qualified Health Center

Indicates primary specialty

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NPI Profile & details for DE BACA FAMILY PRACTICE CLINIC

NPI # 1699082644

LBN Legal business name DE BACA FAMILY PRACTICE CLINIC

Authorized official LISA WALRAVEN - (CEO)

Entity Organization

Organization subpart ¹ Yes

Enumeration date 09/10/2010

Last updated 10/14/2025 - About 8 months ago

Identifiers

NM	License #	3069
NM	Medicaid	38003384

¹ Some organization health care providers are made up of components that furnish different types of health care or have separate physical locations where health care is furnished. These components and physical locations are not themselves legal entities, but are part of the organization health care provider (which is a legal entity). A covered organization provider may decide that its subparts (if it has any) should have their own NPI numbers. If a subpart conducts any HIPAA standard transactions on its own (e.g., separately from its parent), it must obtain its own NPI number.

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