Provider Demographics
NPI:1841436938
Name:LA CLINICA AMISTAD, INC.
Entity type:Organization
Organization Name:LA CLINICA AMISTAD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW-AP
Authorized Official - Phone:210-872-4302
Mailing Address - Street 1:17319 GARWOOD CHASE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-5839
Mailing Address - Country:US
Mailing Address - Phone:210-872-4302
Mailing Address - Fax:
Practice Address - Street 1:17319 GARWOOD CHASE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-5839
Practice Address - Country:US
Practice Address - Phone:210-872-4302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-19
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare