MEDICARE: SU CLINICA FAMILIAR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0002X	Clinic Pharmacy	A07099	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4564527	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1093819062
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SU CLINICA FAMILIAR

Provider Business Mailing Address
First Line	:	1706 TREASURE HILLS BLVD
Second Line	:
City	:	HARLINGEN
State	:	TX
Zip	:	78550-8911
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4000 FM 511
Second Line	:
City	:	BROWNSVILLE
State	:	TX
Zip	:	78526-9492
Country	:	US
Telephone Number	:	956-838-6346
Fax Number	:	956-831-3285

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	ELENA MARIN
Credential	:	MD
Telephone Number	:	956-365-6750

Provider Enumeration Date	:	09/12/2006
Last Update Date	:	08/22/2020

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Directions to “SU CLINICA FAMILIAR ” Practice Location

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