Provider Demographics
NPI:1083961403
Name:RIO GRANDE STATE CENTER
Entity Type:Organization
Organization Name:RIO GRANDE STATE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MORON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-364-8375
Mailing Address - Street 1:1401 S RANGERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78552-7638
Mailing Address - Country:US
Mailing Address - Phone:956-364-8375
Mailing Address - Fax:
Practice Address - Street 1:1401 S RANGERVILLE RD
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78552-7638
Practice Address - Country:US
Practice Address - Phone:956-364-8375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT82349261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service