Provider Demographics
NPI:1760647457
Name:EL CENTRO FAMILY HEALTH
Entity Type:Organization
Organization Name:EL CENTRO FAMILY HEALTH
Other - Org Name:EL CENTRO FAMILY HEALTH SAN MIGUEL 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:505-753-5814
Practice Address - Street 1:275 NM 3
Practice Address - Street 2:
Practice Address - City:RIBERA
Practice Address - State:NM
Practice Address - Zip Code:87560-0277
Practice Address - Country:US
Practice Address - Phone:575-421-1113
Practice Address - Fax:575-421-2943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-23
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6104261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1780689034OtherORGANIZATION NPPES
NM47100Medicaid
NM1780689034OtherORGANIZATION NPPES