Provider Demographics
NPI:1396782264
Name:ENSENADA ADULT DAY CARE
Entity type:Organization
Organization Name:ENSENADA ADULT DAY CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/GENERAL PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:JUAN
Authorized Official - Last Name:GARZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-849-1166
Mailing Address - Street 1:PO BOX 1003
Mailing Address - Street 2:
Mailing Address - City:ROMA
Mailing Address - State:TX
Mailing Address - Zip Code:78584-1003
Mailing Address - Country:US
Mailing Address - Phone:956-849-1166
Mailing Address - Fax:956-849-5070
Practice Address - Street 1:1618 E GRANT ST
Practice Address - Street 2:
Practice Address - City:ROMA
Practice Address - State:TX
Practice Address - Zip Code:78584-8144
Practice Address - Country:US
Practice Address - Phone:956-849-1166
Practice Address - Fax:956-849-5070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115089261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001001547Medicaid