Provider Demographics
NPI:1952555153
Name:CENTRO DE MI SALUD
Entity Type:Organization
Organization Name:CENTRO DE MI SALUD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QMHP
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHEAL
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:RAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:BSW
Authorized Official - Phone:214-941-0798
Mailing Address - Street 1:13043 GEORGE FOSTER RD
Mailing Address - Street 2:
Mailing Address - City:PONDER
Mailing Address - State:TX
Mailing Address - Zip Code:76259-4009
Mailing Address - Country:US
Mailing Address - Phone:214-941-0798
Mailing Address - Fax:214-941-0408
Practice Address - Street 1:628 CENTRE ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-6328
Practice Address - Country:US
Practice Address - Phone:214-941-0798
Practice Address - Fax:214-941-0408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1043204019Medicaid