Provider Demographics
NPI:1053401372
Name:PUEBLO DE SALUD HOME HEALTH SERVICES LLC
Entity type:Organization
Organization Name:PUEBLO DE SALUD HOME HEALTH SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:E
Authorized Official - Last Name:GAONA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-590-3330
Mailing Address - Street 1:PO BOX 26704
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79926-6704
Mailing Address - Country:US
Mailing Address - Phone:915-590-3330
Mailing Address - Fax:915-594-8245
Practice Address - Street 1:3431 PERSHING DR
Practice Address - Street 2:STE A4
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-2754
Practice Address - Country:US
Practice Address - Phone:915-590-3330
Practice Address - Fax:915-594-8245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-15
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2051179Medicaid
TX74-7023Medicare PIN