Healthcare Provider Details

I. General information

NPI: 1750983375
Provider Name (Legal Business Name): CLUB DE ACTIVIDADES SU CASA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 02/24/2023
Certification Date: 08/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5003 ALABAMA ST
EL PASO TX
79930-2615
US

IV. Provider business mailing address

5003 ALABAMA ST
EL PASO TX
79930-2615
US

V. Phone/Fax

Practice location:
  • Phone: 915-566-0800
  • Fax: 915-566-0801
Mailing address:
  • Phone: 915-566-0800
  • Fax: 915-566-0801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. AIDA VARGAS
Title or Position: OWNER
Credential:
Phone: 915-256-9191