1225306525 NPI number — EL CENTRO FAMILY HEALTH

Table of content: (NPI 1225306525)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225306525 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:
1225306525
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2016
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:
505-753-7218
Provider Business Mailing Address Fax Number:
505-753-5815

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
375 EAST 6TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROY
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-485-0019
Provider Business Practice Location Address Fax Number:
575-485-0020
Provider Enumeration Date:
12/01/2011

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: 261QF0400X , with the licence number:  2015/16-19 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1780689034 . This is a "NPPES" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 58957553 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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