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General NPI Number Information
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NPI Number | 1679363030
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Entity Type | Organization
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Legal Business Name | PROJECT VIDA HEALTH CENTER
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Dates
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Enumeration Date | 05/08/2025
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Last Update Date | 05/08/2025
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Provider Practice Location Address
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Address Line | 430 OIL MILL DR
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City | TORNILLO
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State | TX
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Zip | 79853
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Country | US
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Telephone | 915-465-1191
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Fax | 915-533-7158
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Provider Business Mailing Address
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Address Line | 3607 RIVERA AVE
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City | EL PASO
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State | TX
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Zip | 79905-2415
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Country | US
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Telephone | 915-465-1191
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Fax | 915-533-7158
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Authorized Official
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Title or Position | CEO
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Name | TIMOTHY DAVENPORT-HERBST
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Credential |
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Telephone | 915-465-1191
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number |
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License Number State |
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