Provider Demographics
NPI:1295894749
Name:VAL-ROD DBA CLUB DE AMISTAD
Entity type:Organization
Organization Name:VAL-ROD DBA CLUB DE AMISTAD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMADOR
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-859-8671
Mailing Address - Street 1:681 HORIZON BLVD STE G
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:TX
Mailing Address - Zip Code:79927-4692
Mailing Address - Country:US
Mailing Address - Phone:915-860-8690
Mailing Address - Fax:915-859-3985
Practice Address - Street 1:109 CROCKER DR
Practice Address - Street 2:
Practice Address - City:HORIZON CITY
Practice Address - State:TX
Practice Address - Zip Code:79928-7153
Practice Address - Country:US
Practice Address - Phone:915-852-5006
Practice Address - Fax:915-852-2792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA0600X
TX102237261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146065672Medicaid