Provider Demographics
NPI:1376790121
Name:VILLAGE GROUP MANAGEMENT CORP.
Entity Type:Organization
Organization Name:VILLAGE GROUP MANAGEMENT CORP.
Other - Org Name:CENTURY VILLAGE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DOCTOR MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:
Authorized Official - Last Name:GODOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-433-9501
Mailing Address - Street 1:13550 SW 10TH STREET
Mailing Address - Street 2:STE B
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027
Mailing Address - Country:US
Mailing Address - Phone:954-433-9501
Mailing Address - Fax:954-433-8035
Practice Address - Street 1:13550 SW 10TH STREET
Practice Address - Street 2:STE B
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027
Practice Address - Country:US
Practice Address - Phone:954-433-9501
Practice Address - Fax:954-433-8035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-24
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0065758207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK2474OtherVISTA HEALTHPLAN
FL376822800Medicaid
FL110819OtherHUMANA HEALTHPLAN
FL110819OtherHUMANA HEALTHPLAN
FL376822800Medicaid