Healthcare Provider Details

I. General information

NPI: 1568196038
Provider Name (Legal Business Name): YSLETA DEL SUR PUEBLO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/05/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9473 SOCORRO RD
EL PASO TX
79907
US

IV. Provider business mailing address

9473 SOCORRO RD
EL PASO TX
79907-6832
US

V. Phone/Fax

Practice location:
  • Phone: 915-858-1076
  • Fax:
Mailing address:
  • Phone: 915-858-1076
  • Fax: 915-232-9954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: REASOL A CHINO
Title or Position: DIRECTOR
Credential:
Phone: 915-858-1076