=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811061872
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EL CENTRO DEL BARRIO, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2006
-----------------------------------------------------
Last Update Date | 10/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7315 S. LOOP 1604 WEST
-----------------------------------------------------
City | SOMERSET
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-922-7000
-----------------------------------------------------
Fax | 210-924-1374
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3750 COMMERCIAL AVE
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78221-3117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-334-3700
-----------------------------------------------------
Fax | 210-922-0162
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP/CFO
-----------------------------------------------------
Name | CHUCK WALZEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 210-334-3724
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number | HBOCS00758-04-00
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------