Provider Demographics
NPI:1144390147
Name:YSLETA DEL SUR PUEBLO COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:YSLETA DEL SUR PUEBLO COMMUNITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HHS DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-858-1076
Mailing Address - Street 1:9473 SOCORRO RD
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79907-5619
Mailing Address - Country:US
Mailing Address - Phone:915-858-1076
Mailing Address - Fax:915-860-6166
Practice Address - Street 1:9473 SOCORRO RD
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79907
Practice Address - Country:US
Practice Address - Phone:915-860-6113
Practice Address - Fax:915-860-6166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17718261Q00000X
261Q00000X, 261QP0904X
TX1603-1603A261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX092524001Medicaid
TX092524001Medicaid