Provider Demographics
NPI:1376420083
Name:PALM TREE LLC
Entity type:Organization
Organization Name:PALM TREE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:
Authorized Official - Last Name:ABULENCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:671-788-1706
Mailing Address - Street 1:144 KAYEN CHANDO STE 101
Mailing Address - Street 2:
Mailing Address - City:DEDEDO
Mailing Address - State:GU
Mailing Address - Zip Code:96929-4906
Mailing Address - Country:US
Mailing Address - Phone:671-637-4867
Mailing Address - Fax:
Practice Address - Street 1:144 KAYEN CHANDO STE 101
Practice Address - Street 2:
Practice Address - City:DEDEDO
Practice Address - State:GU
Practice Address - Zip Code:96929-4906
Practice Address - Country:US
Practice Address - Phone:671-637-4867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
GU1184990905Medicaid