Provider Demographics
NPI:1891177655
Name:YSLETA DEL SUR PUEBLO
Entity Type:Organization
Organization Name:YSLETA DEL SUR PUEBLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
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 1:9314 JUANCHIDO LN
Mailing Address - Street 2:
Mailing Address - City:YSLETA DEL SUR PUEBLO
Mailing Address - State:TX
Mailing Address - Zip Code:79907-6832
Mailing Address - Country:US
Mailing Address - Phone:915-860-6124
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:79907-6832
Practice Address - Country:US
Practice Address - Phone:915-858-1076
Practice Address - Fax:915-860-6166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-29
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1603-1603A251S00000X
261QP0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTEZ034Medicare PIN