Provider Demographics
NPI:1306583117
Name:FUENTE DE JUVENTUD, INC.
Entity type:Organization
Organization Name:FUENTE DE JUVENTUD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLEGOS
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:956-702-3323
Mailing Address - Street 1:1138 E INTERSTATE 2 STE E
Mailing Address - Street 2:
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-6519
Mailing Address - Country:US
Mailing Address - Phone:956-702-3323
Mailing Address - Fax:956-782-5448
Practice Address - Street 1:2008 REDSKIN AVE STE A
Practice Address - Street 2:
Practice Address - City:DONNA
Practice Address - State:TX
Practice Address - Zip Code:78537-3299
Practice Address - Country:US
Practice Address - Phone:956-377-5158
Practice Address - Fax:956-377-5204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-14
Last Update Date:2022-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8007326201Medicaid