Healthcare Provider Details

I. General information

NPI: 1164782462
Provider Name (Legal Business Name): EL CENTRO FAMILY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 06/07/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15136 ST. RD.
PENASCO NM
87553-0000
US

IV. Provider business mailing address

538 N PASEO DE ONATE P.O. BOX 158
ESPANOLA NM
87532-2618
US

V. Phone/Fax

Practice location:
  • Phone: 575-587-2809
  • Fax: 575-587-2605
Mailing address:
  • Phone: 505-752-7218
  • Fax: 505-753-5815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MRS. LORE PEASE
Title or Position: CEO
Credential: CEO
Phone: 505-753-7218