Provider Demographics
NPI:1003951963
Name:CENTROSALUD PC
Entity Type:Organization
Organization Name:CENTROSALUD PC
Other - Org Name:LIFEDOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:B
Authorized Official - Last Name:COWAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-531-8800
Mailing Address - Street 1:6063 MOUNT MORIAH ROAD EXT
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-2644
Mailing Address - Country:US
Mailing Address - Phone:901-531-8800
Mailing Address - Fax:901-531-8801
Practice Address - Street 1:1068 CRESTHAVEN RD
Practice Address - Street 2:SUITE 300
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0800
Practice Address - Country:US
Practice Address - Phone:901-683-0024
Practice Address - Fax:901-683-0028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD000035089174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3728771OtherMEDICARE PROVIDER NUMBER
TN3728771OtherMEDICARE PROVIDER NUMBER