1457798712 NPI number — EL CENTRO FAMILY HEALTH

Table of content: (NPI 1457798712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457798712 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:
1457798712
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2014
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:
1260 INDUSTRIAL PARK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ESPANOLA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87532-3503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-753-1348
Provider Business Practice Location Address Fax Number:
505-747-7332
Provider Enumeration Date:
05/28/2013

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 , 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: 215159844 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1780689034 . This is a "NPPES" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".




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