MEDICARE: EL PASO DIABETES ASSOCIATION, 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	133VN1006X	Metabolic Nutrition Registered Dietitian
2	251V00000X	Voluntary or Charitable Agency		TX

General Provider Information

NPI Number	:	1548580491
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EL PASO DIABETES ASSOCIATION, INC.

Provider Business Mailing Address
First Line	:	3641 MATTOX ST
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79925-1307
Country	:	US
Telephone Number	:	915-532-6280
Fax Number	:	915-598-3732

Provider Business Practice Location Address
First Line	:	3641 MATTOX ST
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79925-1307
Country	:	US
Telephone Number	:	915-532-6280
Fax Number	:	915-598-3732

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. SANDRA GONZALEZ
Credential	:
Telephone Number	:	915-532-6280

Provider Enumeration Date	:	06/02/2010
Last Update Date	:	08/07/2023

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