Healthcare Provider Details

I. General information

NPI: 1790940716
Provider Name (Legal Business Name): EL CENTRO FAMILY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STATE ROAD 75 #15136
PENASCO NM
87553-2627
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: 575-587-2205
  • Fax: 575-587-1944
Mailing address:
  • Phone: 505-753-7218
  • Fax: 505-753-5815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number6102
License Number StateNM

VIII. Authorized Official

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