Provider Demographics
NPI:1922478114
Name:SOCORRO MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:SOCORRO MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADEKUNLE
Authorized Official - Middle Name:ADEDAYO
Authorized Official - Last Name:ADEDEJI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:915-351-4010
Mailing Address - Street 1:PO BOX 221287
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79913-4287
Mailing Address - Country:US
Mailing Address - Phone:915-351-4010
Mailing Address - Fax:
Practice Address - Street 1:10720 N LOOP DR
Practice Address - Street 2:SUITE A
Practice Address - City:SOCORRO
Practice Address - State:TX
Practice Address - Zip Code:79927-4409
Practice Address - Country:US
Practice Address - Phone:915-351-4010
Practice Address - Fax:915-309-1816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3416207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty