Basic Information
| Provider Information | |||||||||
| NPI: | 1164748216 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELDORADO TEXAS COMMUNITY SERVICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5510 N CAGE BLVD | ||||||||
| Address2: | SUITE 9 | ||||||||
| City: | PHARR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785771812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612546630 | ||||||||
| FaxNumber: | 6612546644 | ||||||||
| Practice Location | |||||||||
| Address1: | 5510 N CAGE BLVD | ||||||||
| Address2: | SUITE 9 | ||||||||
| City: | PHARR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785771812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612546630 | ||||||||
| FaxNumber: | 6612546644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2010 | ||||||||
| LastUpdateDate: | 04/14/2010 | ||||||||
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| AuthorizedOfficialLastName: | SHARMA | ||||||||
| AuthorizedOfficialFirstName: | PRAMESH | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6612546630 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | TX-10240-M | 01 | TX | SAMHSA | OTHER |