Provider Demographics
NPI:1508183385
Name:NEW LIGHT PRIMARY CARE P. A
Entity Type:Organization
Organization Name:NEW LIGHT PRIMARY CARE P. A
Other - Org Name:NEW LIGHT PRIMARY CARE PA
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANQUERO-BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-772-5400
Mailing Address - Street 1:3615 RUTHERGLEN ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-1416
Mailing Address - Country:US
Mailing Address - Phone:915-772-5400
Mailing Address - Fax:915-772-5402
Practice Address - Street 1:3615 RUTHERGLEN ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-1416
Practice Address - Country:US
Practice Address - Phone:915-772-5400
Practice Address - Fax:915-772-5402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB104258Medicaid