Basic Information
| Provider Information | |||||||||
| NPI: | 1811042567 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EL CENTRO DEL BARRIO, INC. | ||||||||
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| OtherOrganizationName: | CENTROMED SOUTH PARK DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3750 COMMERCIAL AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782213117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103343700 | ||||||||
| FaxNumber: | 2109220162 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 WAGNER AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782113213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109247344 | ||||||||
| FaxNumber: | 2109237929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 05/09/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WALZEL | ||||||||
| AuthorizedOfficialFirstName: | CHUCK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2103343724 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | HBOCS00758-04-00 | TX | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 261QS0112X | HBOCS00758-04-00 | TX | N | Ambulatory Health Care Facilities | Clinic/Center | Oral and Maxillofacial Surgery | 261QF0400X | HBOCS00758-04-00 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 120980101 | 05 | TX | MEDICAID | 120980105 | 05 | TX | MEDICAID | 120980103 | 05 | TX | MEDICAID | 120980102 | 05 | TX | MEDICAID | 00MT08 | 01 | TX | GROUP MEDICARE | OTHER |