Provider Demographics
NPI:1841664067
Name:CENTRO MEDICO FAMILIAR EBENEZER
Entity type:Organization
Organization Name:CENTRO MEDICO FAMILIAR EBENEZER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NP
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:COSME-THILLET
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:210-997-0103
Mailing Address - Street 1:8212 HEIGHTS VLY
Mailing Address - Street 2:
Mailing Address - City:CONVERSE
Mailing Address - State:TX
Mailing Address - Zip Code:78109-3502
Mailing Address - Country:US
Mailing Address - Phone:210-709-8760
Mailing Address - Fax:210-375-6148
Practice Address - Street 1:5650 N FOSTER RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78244-1106
Practice Address - Country:US
Practice Address - Phone:210-997-0103
Practice Address - Fax:210-375-6148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-27
Last Update Date:2015-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP 124023261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care