Provider Demographics
NPI:1992139349
Name:MLK MEDICAL CENTER
Entity type:Organization
Organization Name:MLK MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OSVALDO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1813-443-2191
Mailing Address - Street 1:1936 W DR MARTIN LUTHER KING JR BLVD STE 209
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6530
Mailing Address - Country:US
Mailing Address - Phone:813-443-2191
Mailing Address - Fax:813-443-4823
Practice Address - Street 1:1936 W DR MARTIN LUTHER KING JR BLVD STE 209
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6530
Practice Address - Country:US
Practice Address - Phone:813-443-2191
Practice Address - Fax:813-443-4823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center