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General NPI Number Information
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NPI Number | 1841664067
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Entity Type | Organization
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Legal Business Name | CENTRO MEDICO FAMILIAR EBENEZER
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Dates
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Enumeration Date | 11/27/2015
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Last Update Date | 11/27/2015
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Provider Practice Location Address
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Address Line | 5650 N FOSTER RD
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City | SAN ANTONIO
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State | TX
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Zip | 78244-1106
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Country | US
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Telephone | 210-997-0103
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Fax | 210-375-6148
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Provider Business Mailing Address
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Address Line | 8212 HEIGHTS VLY
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City | CONVERSE
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State | TX
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Zip | 78109-3502
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Country | US
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Telephone | 210-709-8760
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Fax | 210-375-6148
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Authorized Official
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Title or Position | OWNER/NP
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Name | CARLOS ALBERTO COSME-THILLET
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Credential | NP
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Telephone | 210-997-0103
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | AP 124023
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License Number State | TX
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