Healthcare Provider Details

I. General information

NPI: 1548580491
Provider Name (Legal Business Name): EL PASO DIABETES ASSOCIATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2010
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3641 MATTOX ST
EL PASO TX
79925-1307
US

IV. Provider business mailing address

3641 MATTOX ST
EL PASO TX
79925-1307
US

V. Phone/Fax

Practice location:
  • Phone: 915-532-6280
  • Fax: 915-598-3732
Mailing address:
  • Phone: 915-532-6280
  • Fax: 915-598-3732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateTX

VIII. Authorized Official

Name: MS. SANDRA GONZALEZ
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 915-532-6280