Provider Demographics
NPI:1841480902
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 1:1208 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79901-1602
Mailing Address - Country:US
Mailing Address - Phone:915-351-8972
Mailing Address - Fax:
Practice Address - Street 1:1208 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79901-1602
Practice Address - Country:US
Practice Address - Phone:915-351-8972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
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
TX130880107Medicaid