Provider Demographics
NPI:1811042567
Name:EL CENTRO DEL BARRIO, INC.
Entity Type:Organization
Organization Name:EL CENTRO DEL BARRIO, INC.
Other - Org Name:CENTROMED SOUTH PARK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:WALZEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-334-3724
Mailing Address - Street 1:3750 COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78221-3117
Mailing Address - Country:US
Mailing Address - Phone:210-334-3700
Mailing Address - Fax:210-922-0162
Practice Address - Street 1:910 WAGNER AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78211-3213
Practice Address - Country:US
Practice Address - Phone:210-924-7344
Practice Address - Fax:210-923-7929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXHBOCS00758-04-001223G0001X, 261QF0400X, 261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120980101Medicaid
TX120980105Medicaid
TX120980103Medicaid
TX120980102Medicaid
TX00MT08OtherGROUP MEDICARE
TX00MT08OtherGROUP MEDICARE