Healthcare Provider Details

I. General information

NPI: 1649411463
Provider Name (Legal Business Name): PROJECT VIDA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2009
Last Update Date: 03/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3607 RIVERA AVE
EL PASO TX
79905-2415
US

IV. Provider business mailing address

3612 PERA AVE
EL PASO TX
79905-2412
US

V. Phone/Fax

Practice location:
  • Phone: 915-757-0038
  • Fax: 915-757-1640
Mailing address:
  • Phone: 915-533-7057
  • Fax: 915-533-7197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License NumberPA03671
License Number StateTX

VIII. Authorized Official

Name: MS. JOSIE L MENDEZ
Title or Position: ASSISTANT BUSINESS MANAGER
Credential:
Phone: 915-757-0038