=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891793246
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NUESTRA CLINICA DEL VALLE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2005
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 W 1ST STREET
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78589
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-787-8915
-----------------------------------------------------
Fax | 956-787-2021
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1689
-----------------------------------------------------
City | PHARR
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78577-1630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 956-787-8915
-----------------------------------------------------
Fax | 956-787-2021
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MRS. MARIA L TORRES
-----------------------------------------------------
Credential | BBA
-----------------------------------------------------
Telephone | 956-787-8915
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------