Basic Information
| Provider Information | |||||||||
| NPI: | 1518122704 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VA CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5001 N PIEDRAS ST | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799304210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155646100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5001 N PIEDRAS ST | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799304210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155646100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2008 | ||||||||
| LastUpdateDate: | 07/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | DANIELS | ||||||||
| AuthorizedOfficialFirstName: | NEDA | ||||||||
| AuthorizedOfficialMiddleName: | AMINTA | ||||||||
| AuthorizedOfficialTitleorPosition: | RN/PRIMARY CARE UNIT | ||||||||
| AuthorizedOfficialTelephone: | 9154128231 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 689712 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 528565881 | 05 | TX | MEDICAID |