| Sun City Sports Medicine And Family Clinic, Pa | |
|
12810 Edgemere Blvd El Paso TX 79938-4532 | |
| (915) 504-6955 | |
| (915) 504-6954 |
| Full Name | Sun City Sports Medicine And Family Clinic, Pa |
|---|---|
| Speciality | Family Medicine |
| Location | 12810 Edgemere Blvd, El Paso, Texas |
| Authorized Official Name and Position | Mauro Provencio (MD/OWNER) |
| Authorized Official Contact | 9155253209 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Sun City Sports Medicine And Family Clinic, Pa 12810 Edgemere Blvd El Paso TX 79938-4532 Ph: (915) 222-8747 | Sun City Sports Medicine And Family Clinic, Pa 12810 Edgemere Blvd El Paso TX 79938-4532 Ph: (915) 504-6955 |
| NPI Number | 1114289956 |
|---|---|
| Provider Enumeration Date | 06/07/2012 |
| Last Update Date | 06/18/2024 |
| Medicare PECOS PAC ID | 9830355130 |
|---|---|
| Medicare Enrollment ID | O20120731000329 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1114289956 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207QS0010X | Family Medicine - Sports Medicine | P1809 (Texas) | Primary |
| Provider Name | Mauro Provencio |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1952560682 PECOS PAC ID: 0840456141 Enrollment ID: I20120731000318 |
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