Provider Demographics
NPI:1598574139
Name:CENTRUM MEDICAL HOLDING OF LAKE WORTH
Entity type:Organization
Organization Name:CENTRUM MEDICAL HOLDING OF LAKE WORTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:GRACIELA
Authorized Official - Middle Name:VANESSA
Authorized Official - Last Name:VICTORERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-266-2929
Mailing Address - Street 1:9250 NW 36TH ST STE 420
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2775
Mailing Address - Country:US
Mailing Address - Phone:305-266-2929
Mailing Address - Fax:
Practice Address - Street 1:4560 LANTANA RD
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-6998
Practice Address - Country:US
Practice Address - Phone:305-266-2929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-07
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty