Healthcare Provider Details

I. General information

NPI: 1467583286
Provider Name (Legal Business Name): MAVERICK COUNTY MEDICAL FAMILY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 E MAIN ST STE A
EAGLE PASS TX
78852-4773
US

IV. Provider business mailing address

2239 ACAPULCO DR
EAGLE PASS TX
78852-4101
US

V. Phone/Fax

Practice location:
  • Phone: 830-773-3331
  • Fax: 830-773-2981
Mailing address:
  • Phone: 210-394-9171
  • Fax: 830-773-2981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number StateNULL

VIII. Authorized Official

Name: ELIZABETH SOSA
Title or Position: CREDENTIALING AND ENROLLMENT MANAGE
Credential:
Phone: 508-213-1947