Provider Demographics
NPI:1780761452
Name:CENTRO SAN VICENTE
Entity type:Organization
Organization Name:CENTRO SAN VICENTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
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:PO BOX 1517
Mailing Address - Street 2:
Mailing Address - City:SAN ELIZARIO
Mailing Address - State:TX
Mailing Address - Zip Code:79849-1517
Mailing Address - Country:US
Mailing Address - Phone:915-851-0999
Mailing Address - Fax:915-851-6060
Practice Address - Street 1:13017 PERICO ST
Practice Address - Street 2:
Practice Address - City:SAN ELIZARIO
Practice Address - State:TX
Practice Address - Zip Code:79849-1517
Practice Address - Country:US
Practice Address - Phone:915-851-0999
Practice Address - Fax:915-851-6060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX130880102Medicaid
TX00B14GMedicare Oscar/Certification
TX451916Medicare Oscar/Certification