Basic Information
| Provider Information | |||||||||
| NPI: | 1467592683 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EL CENTRO DEL BARRIO INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CENTROMED PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3750 COMMERCIAL AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782213117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103343700 | ||||||||
| FaxNumber: | 2109220162 | ||||||||
| Practice Location | |||||||||
| Address1: | 918 WAGNER | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782113218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109323500 | ||||||||
| FaxNumber: | 2109246778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 11/03/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALZEL | ||||||||
| AuthorizedOfficialFirstName: | CHUCK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2103343724 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | HBOCS007580400 | TX | N | Suppliers | Pharmacy | Clinic Pharmacy | 261QF0400X | HBOCS007580400 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 120980102 | 05 | TX | MEDICAID | 120980103 | 05 | TX | MEDICAID | 4587537 | 01 | TX | NABP | OTHER | 00MT08 | 01 | TX | GROUP MEDICARE | OTHER | 120980101 | 05 | TX | MEDICAID |