| Full Name | |
|---|---|
| Speciality | Clinic/center - Federally Qualified Health Center (fqhc) |
| Location | 678 Avenue C, Fort Sumner, New Mexico |
| Authorized Official Name and Position | Lisa Walraven (CEO) |
| Authorized Official Contact | 5753552420 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 349 Fort Sumner NM 88119-0349 Ph: (575) 355-2414 | 678 Avenue C Fort Sumner NM 88119 Ph: (575) 355-2417 |
| NPI Number | 1740090729 |
|---|---|
| Provider Enumeration Date | 01/10/2025 |
| Last Update Date | 01/22/2025 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1740090729 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | (* (Not Available)) | Secondary |
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |