MEDICARE: EL CENTRO FAMILY HEALTH

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	261QF0400X	Federally Qualified Health Center (FQHC)	02932	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1780689034	OTHER	NM	NPPES

General Provider Information

NPI Number	:	1548537830
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EL CENTRO FAMILY HEALTH

Provider Business Mailing Address
First Line	:	538 N PASEO DE ONATE
Second Line	:	P.O. BOX 158
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2618
Country	:	US
Telephone Number	:	505-753-7218
Fax Number	:	505-753-5815

Provider Business Practice Location Address
First Line	:	1024 SOUTH PACIFIC
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701
Country	:	US
Telephone Number	:	505-426-2599
Fax Number	:	505-426-2579

Authorized Official
Title or Position	:	CEO
Name	:	MRS. LORE PEASE
Credential	:
Telephone Number	:	505-753-7218

Provider Enumeration Date	:	11/30/2011
Last Update Date	:	11/21/2014

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