Basic Information
| Provider Information | |||||||||
| NPI: | 1649411463 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROJECT VIDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3612 PERA AVE | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799052412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155337057 | ||||||||
| FaxNumber: | 9155337197 | ||||||||
| Practice Location | |||||||||
| Address1: | 3607 RIVERA AVE | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799052415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157570038 | ||||||||
| FaxNumber: | 9157571640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2009 | ||||||||
| LastUpdateDate: | 03/09/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MENDEZ | ||||||||
| AuthorizedOfficialFirstName: | JOSIE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9157570038 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | PA03671 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | PA03671 | 01 | TX | PA LICENSE | OTHER |