Provider Demographics
NPI:1427458868
Name:LWCMDIV, LLC
Entity type:Organization
Organization Name:LWCMDIV, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:LA TORRE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:727-321-6130
Mailing Address - Street 1:2150 49TH ST N
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-5237
Mailing Address - Country:US
Mailing Address - Phone:727-321-6130
Mailing Address - Fax:727-327-2677
Practice Address - Street 1:2150 49TH ST N
Practice Address - Street 2:SUITE C
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-5237
Practice Address - Country:US
Practice Address - Phone:727-321-6130
Practice Address - Fax:727-327-2677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty