Healthcare Provider Details

I. General information

NPI: 1689131427
Provider Name (Legal Business Name): LOS PORTALES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HIGHWAY 28
ANTHONY NM
88021-8546
US

IV. Provider business mailing address

PO BOX 13489
EL PASO TX
79913-3489
US

V. Phone/Fax

Practice location:
  • Phone: 915-229-0125
  • Fax:
Mailing address:
  • Phone: 915-229-0125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. OSCAR DEL VALLE
Title or Position: MANAGER
Credential:
Phone: 915-229-0125