1164782462 NPI number — EL CENTRO FAMILY HEALTH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164782462 NPI number — EL CENTRO FAMILY HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EL CENTRO FAMILY HEALTH
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:
Provider Other Organization Name Type Code:
6
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:
1164782462
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
538 N PASEO DE ONATE
Provider Second Line Business Mailing Address:
P.O. BOX 158
Provider Business Mailing Address City Name:
ESPANOLA
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87532-2618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-752-7218
Provider Business Mailing Address Fax Number:
505-753-5815

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15136 ST. RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENASCO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87553-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-587-2809
Provider Business Practice Location Address Fax Number:
575-587-2605
Provider Enumeration Date:
05/21/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PEASE
Authorized Official First Name:
LORE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
505-753-7218

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1780689034 . This is a "ORGANIZATION NPPES" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 47092 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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