Provider Demographics
NPI:1710049218
Name:LA FAMILIA MEDICAL CENTER
Entity type:Organization
Organization Name:LA FAMILIA MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:VANESSA
Authorized Official - Last Name:VAN PELT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-982-4425
Mailing Address - Street 1:2145 CAJA DEL ORO GRANT RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-3279
Mailing Address - Country:US
Mailing Address - Phone:505-982-4415
Mailing Address - Fax:505-982-1263
Practice Address - Street 1:2145 CAJA DEL ORO GRANT RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-3279
Practice Address - Country:US
Practice Address - Phone:505-438-3195
Practice Address - Fax:505-982-6280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X, 207Q00000X
NM321876261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMB3367Medicaid
NMB3367Medicaid