Provider Demographics
NPI:1669930392
Name:EL CENTRO FAMILY HEALTH
Entity type:Organization
Organization Name:EL CENTRO FAMILY HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:TYWAN
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-747-5939
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0158
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-747-7396
Practice Address - Street 1:1401 8TH STREET
Practice Address - Street 2:
Practice Address - City:SPRINGER
Practice Address - State:NM
Practice Address - Zip Code:87747
Practice Address - Country:US
Practice Address - Phone:505-753-7218
Practice Address - Fax:505-747-5946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)