Provider Demographics
NPI:1942670328
Name:CENTRO SAN VICENTE
Entity Type:Organization
Organization Name:CENTRO SAN VICENTE
Other - Org Name:CENTRO SAN VICENTE'S WELLNESS CENTER AT EMERGENCE HEALTHCARE NETWORK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:915-225-0670
Mailing Address - Street 1:1600 MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-5622
Mailing Address - Country:US
Mailing Address - Phone:915-859-7545
Mailing Address - Fax:
Practice Address - Street 1:1600 MONTANA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-5622
Practice Address - Country:US
Practice Address - Phone:915-859-7545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-29
Last Update Date:2015-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX451901Medicare Oscar/Certification
TX00B14GMedicare Oscar/Certification