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CH06301M LA CLINICA DE FAMILIA, INC (Terminated)
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Main Details
Name
LA CLINICA DE FAMILIA, INC
Subdivision Name
ANTHONY DENTAL CLINIC
Type
HRSA-Funded Health Center
Site ID
BPS-H80-001789
340B ID
CH06301M
Grant Number
H80CS00316
Additional Details
Current Program Status
Terminated
Registration Date
3/4/2009
Participating Start Date
4/1/2009
Participating Approval Date
3/5/2009
Last Recertification Date
2/26/2018
Termination Date
Termination Reason
4/1/2018
Other
Contacts
Authorizing Official
La Clinica de Familia, Inc.
Virgil Medina, CEO
(575) 526-1105
Primary Contact
La Clinica de Familia, Inc.
Olivia Martinez, Accounting Manager
(575) 526-1105
Addresses
Street Address
855 Anthony Drive
Anthony, NM 88021
Billing Address
LA CLINICA DE FAMILIA, INC.,
385 Calle De Alegra
LAS CRUCES, NM 88005
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Grantee Sites
Grantee Sites Contract Pharmacies
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3/8/12 - Changed billing address from 1100 SOUTH MAIN ST. 11/4/11 - Changed AO from HARRIET BRANDSTETTER.
03/08/2012
11/4/11 - Changed AO from HARRIET BRANDSTETTER.
11/04/2011
June 2025
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