Healthcare Provider Details

I. General information

NPI: 1891177655
Provider Name (Legal Business Name): YSLETA DEL SUR PUEBLO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9473 SOCORRO RD
EL PASO TX
79907-6832
US

IV. Provider business mailing address

9314 JUANCHIDO LN
YSLETA DEL SUR PUEBLO TX
79907-6832
US

V. Phone/Fax

Practice location:
  • Phone: 915-858-1076
  • Fax: 915-860-6166
Mailing address:
  • Phone: 915-860-6124
  • Fax: 915-860-6166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1603-1603A
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARTIN LOPEZ
Title or Position: DIRECTOR
Credential:
Phone: 915-858-1076