32D0863876 CLIA NUMBER - DE BACA FAMILY PRACTICE CLINIC MINI LAB & SBHC

Laboratory Demographics

  • CLIA Code: 32D0863876
  • Facility Name: DE BACA FAMILY PRACTICE CLINIC MINI LAB & SBHC
  • Facility Address: 546 NORTH TENTH STREET
    FORT SUMNER, NM
    ZIP 88119
  • Facility Phone: 505 355-2414
  • Facility Type: Federally Qualified Health Center
  • Facility Type: Waiver
  • Lab Director: JACK VICK
  • NPI Number: 1003855032
  • Taxonomy: 261QF0400X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 32D0863876
LAB Type Federally Qualified Health Center
Facility Name DE BACA FAMILY PRACTICE CLINIC MINI LAB & SBHC
Street 546 NORTH TENTH STREET
City FORT SUMNER
State NM
ZIP 88119
Phone 505 355-2414
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 4/18/2024
Certificate Expiration Date 4/17/2026
Facility Type Federally Qualified Health Center
Lab Director JACK VICK

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This page was last updated on: 9/29/2025