Provider Demographics
NPI:1396780185
Name:MEDICAL CORAL WAY CENTER CORP
Entity type:Organization
Organization Name:MEDICAL CORAL WAY CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-429-3122
Mailing Address - Street 1:1401 S MILITARY TRL
Mailing Address - Street 2:SUITE C
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33415-5720
Mailing Address - Country:US
Mailing Address - Phone:561-429-3122
Mailing Address - Fax:561-429-3124
Practice Address - Street 1:1401 S MILITARY TRL
Practice Address - Street 2:SUITE C-1
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33415-5720
Practice Address - Country:US
Practice Address - Phone:561-429-3122
Practice Address - Fax:561-429-3124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC4058OtherHEALTH CARE CLINIC LICENS
FL74566Medicare PIN
FLHCC4058OtherHEALTH CARE CLINIC LICENS
FL78736XMedicare PIN
FLE7045WMedicare PIN