Provider Demographics
NPI:1619132362
Name:EL CENTRO FAMILY HEALTH
Entity Type:Organization
Organization Name:EL CENTRO FAMILY HEALTH
Other - Org Name:EL CENTRO FAMILY HEALTH COYOTE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORE
Authorized Official - Middle Name:
Authorized Official - Last Name:PEASE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-753-7218
Mailing Address - Street 1:538 N PASEO DE ONATE
Mailing Address - Street 2:P.O. BOX 158
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2618
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-753-5815
Practice Address - Street 1:STATE ROAD 96
Practice Address - Street 2:HOUSE #3396
Practice Address - City:COYOTE
Practice Address - State:NM
Practice Address - Zip Code:87012-0040
Practice Address - Country:US
Practice Address - Phone:575-638-5487
Practice Address - Fax:575-638-9123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6000261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM47142Medicaid
NM1780389034OtherORGANIZATION NPPES
NM1780389034OtherORGANIZATION NPPES