1497935233 NPI number — EL CENTRO DEL BARRIO INC

Table of content: (NPI 1497935233)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497935233 NPI number — EL CENTRO DEL BARRIO INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EL CENTRO DEL BARRIO INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CENTROMED SOUTH PARK DENTAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497935233
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3750 COMMERCIAL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78221-3117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-334-3700
Provider Business Mailing Address Fax Number:
210-922-0162

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
910 WAGNER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78211-3213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-924-7344
Provider Business Practice Location Address Fax Number:
210-923-7929
Provider Enumeration Date:
11/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WALZEL
Authorized Official First Name:
CHUCK
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
210-334-3724

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  HBOCS00758-04-00 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X , with the licence number: HBOCS00758-04-00 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X , with the licence number: HBOCS007758-04-00 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 120980103 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00MT08 . This is a "GROUP MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 120980102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102980101 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: G60232-02 . This is a "DELTA DENTAL" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 120980105 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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