| Organization Name: | DE BACA FAMILY PRACTICE CLINIC |
| NPI Number: | 1003855032 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | GLYNDA SCOVEL (CEO) |
| Mailing Address: | 546 N. Tenth St Fort Sumner |
| State: | NM US |
| Postal Code: | 88119 |
| Phone Number: | 5053552414 |
| Fax Number: | |
| NPI Enumeration Date: | 06/05/2006 |
| NPI Last Update Date: | 07/22/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QF0400X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Federally Qualified Health Center (FQHC) |
| Taxonomy Definition: | |