MEDICARE: LA BLANCA FAMILY CLINIC, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	J6969	TX
2	363LP2300X	Primary Care Nurse Practitioner	580338	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134149040
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA BLANCA FAMILY CLINIC, INC

Provider Business Mailing Address
First Line	:	PO BOX 686
Second Line	:
City	:	LA BLANCA
State	:	TX
Zip	:	78558-0686
Country	:	US
Telephone Number	:	956-262-9823
Fax Number	:	956-262-9622

Provider Business Practice Location Address
First Line	:	18360 FM 493
Second Line	:	SUITE 1
City	:	EDINBURG
State	:	TX
Zip	:	78542-1869
Country	:	US
Telephone Number	:	956-262-9823
Fax Number	:	956-262-9622

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. ISABEL GUZMAN
Credential	:	ANP
Telephone Number	:	956-262-9823

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	10/29/2010

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