1093819062 NPI number — SU CLINICA FAMILIAR

Table of content: (NPI 1093819062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093819062 NPI number — SU CLINICA FAMILIAR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SU CLINICA FAMILIAR
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:
SOUTHERN CAMERON COUNTY CLINIC
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:
1093819062
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1706 TREASURE HILLS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARLINGEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78550-8911
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4000 FM 511
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROWNSVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78526-9492
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-838-6346
Provider Business Practice Location Address Fax Number:
956-831-3285
Provider Enumeration Date:
09/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MARIN
Authorized Official First Name:
ELENA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
956-365-6750

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X , with the licence number:  A07099 , 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: 4564527 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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