Healthcare Provider Details

I. General information

NPI: 1679162101
Provider Name (Legal Business Name): LA CLINICA TEPEYAC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 01/11/2021
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 LINCOLN ST
DENVER CO
80216-2056
US

IV. Provider business mailing address

4725 HIGH ST
DENVER CO
80216-2220
US

V. Phone/Fax

Practice location:
  • Phone: 303-458-5302
  • Fax: 303-583-0152
Mailing address:
  • Phone: 303-458-5302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: JIM GARCIA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 303-458-5302