Healthcare Provider Details

I. General information

NPI: 1053046623
Provider Name (Legal Business Name): GREEN MOUNTAIN HEALTHCARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2022
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2311 N MESA ST STE H
EL PASO TX
79902-3575
US

IV. Provider business mailing address

2311 N MESA ST STE H
EL PASO TX
79902-3575
US

V. Phone/Fax

Practice location:
  • Phone: 915-500-4883
  • Fax: 915-275-5510
Mailing address:
  • Phone: 915-500-4883
  • Fax: 915-275-5510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERTO FLORES
Title or Position: ADMINISTRATOR/OWNER
Credential:
Phone: 915-276-0865