Provider Demographics
NPI:1114289956
Name:SUN CITY SPORTS MEDICINE AND FAMILY CLINIC, PA
Entity Type:Organization
Organization Name:SUN CITY SPORTS MEDICINE AND FAMILY CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAURO
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVENCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-525-3209
Mailing Address - Street 1:1500 FINSTERWALD PL
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79936-6011
Mailing Address - Country:US
Mailing Address - Phone:915-222-8747
Mailing Address - Fax:
Practice Address - Street 1:3270 JOE BATTLE BLVD
Practice Address - Street 2:SUITE 150
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79938-2639
Practice Address - Country:US
Practice Address - Phone:915-504-6955
Practice Address - Fax:915-504-6954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-07
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1809207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty