Healthcare Provider Details

I. General information

NPI: 1497935233
Provider Name (Legal Business Name): EL CENTRO DEL BARRIO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 06/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 WAGNER AVE
SAN ANTONIO TX
78211-3213
US

IV. Provider business mailing address

3750 COMMERCIAL AVE
SAN ANTONIO TX
78221-3117
US

V. Phone/Fax

Practice location:
  • Phone: 210-924-7344
  • Fax: 210-923-7929
Mailing address:
  • Phone: 210-334-3700
  • Fax: 210-922-0162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberHBOCS00758-04-00
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberHBOCS00758-04-00
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License NumberHBOCS007758-04-00
License Number StateTX

VIII. Authorized Official

Name: CHUCK WALZEL
Title or Position: CFO
Credential:
Phone: 210-334-3724