=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104155662
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POR SU SALUD FAMILY CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2009
-----------------------------------------------------
Last Update Date | 12/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 208 LINDBERG AVE
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78501-2920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-292-5102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 208 LINDBERG AVE
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78501-2920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-292-5102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. ELIZABETH HUERTA
-----------------------------------------------------
Credential | RN FNP
-----------------------------------------------------
Telephone | 956-292-5102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 638649
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------