Basic Information
| Provider Information | |||||||||
| NPI: | 1124507272 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROJECT VIDA HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOCORRO HIGH SCHOOL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3607 RIVERA AVE | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799052415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155337057 | ||||||||
| FaxNumber: | 9155337158 | ||||||||
| Practice Location | |||||||||
| Address1: | 10150 ALAMEDA AVE | ||||||||
| Address2: | |||||||||
| City: | SOCORRO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799271600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155337057 | ||||||||
| FaxNumber: | 9154402919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2018 | ||||||||
| LastUpdateDate: | 03/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | SCHLESINGER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9155337057 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.