1376242917 NPI number — CENTERWELL SENIOR PRIMARY CARE SC JV PC

Table of content: (NPI 1376242917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376242917 NPI number — CENTERWELL SENIOR PRIMARY CARE SC JV PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTERWELL SENIOR PRIMARY CARE SC JV PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376242917
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6101 BLUE LAGOON DR STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33126-3168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-500-2000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3725 RENEE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29579-4109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-350-1124
Provider Business Practice Location Address Fax Number:
877-452-8854
Provider Enumeration Date:
03/02/2023

Additional Information

Authorized Official

Authorized Official Last Name:
MARTINEZ
Authorized Official First Name:
ANGIE
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR CREDENTIALING PROFESSIONAL
Authorized Official Telephone Number:
407-447-7120

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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