Provider Demographics
NPI:1538581863
Name:SANTA MARIA MEDICAL GROUP, INC.DBA/ST. MARY'S PHC
Entity type:Organization
Organization Name:SANTA MARIA MEDICAL GROUP, INC.DBA/ST. MARY'S PHC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:CANELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-389-5935
Mailing Address - Street 1:1003 FAIR AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78223-1327
Mailing Address - Country:US
Mailing Address - Phone:210-389-5935
Mailing Address - Fax:
Practice Address - Street 1:1003 FAIR AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-1327
Practice Address - Country:US
Practice Address - Phone:210-389-5935
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX015881311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility