Basic Information
| Provider Information | |||||||||
| NPI: | 1801389044 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EL CENTRO DEL BARRIO, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTROMED INDIAN CREEK CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3750 COMMERCIAL AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782213117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109227000 | ||||||||
| FaxNumber: | 2104573392 | ||||||||
| Practice Location | |||||||||
| Address1: | 5439 RAY ELLISON BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782422219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109227000 | ||||||||
| FaxNumber: | 2104573392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2018 | ||||||||
| LastUpdateDate: | 01/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | WALZEL | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | VP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 2103343724 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CPA, MBA | ||||||||
| NPICertificationDate: | |||||||||
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.