MEDICARE: LA CLINICA GUADALUPANA, INC

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	261QP2300X	Primary Care Clinic/Center		TX

General Provider Information

NPI Number	:	1417958901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LA CLINICA GUADALUPANA, INC

Provider Business Mailing Address
First Line	:	901 ASCENCION ST
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79928-9080
Country	:	US
Telephone Number	:	915-852-3328
Fax Number	:	915-852-4246

Provider Business Practice Location Address
First Line	:	901 ASCENCION ST
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79928-9080
Country	:	US
Telephone Number	:	915-852-3328
Fax Number	:	915-852-4246

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MS. MARGARET RENEE DENEWETH
Credential	:	RN
Telephone Number	:	915-526-4181

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	08/22/2020

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