Provider Demographics
NPI:1417642711
Name:PALM MEDICAL CENTER LAKELAND LLC
Entity Type:Organization
Organization Name:PALM MEDICAL CENTER LAKELAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CENTER OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SANTIAGO
Authorized Official - Middle Name:
Authorized Official - Last Name:MOISES MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-913-9441
Mailing Address - Street 1:2600 S DOUGLAS RD STE 308
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-6134
Mailing Address - Country:US
Mailing Address - Phone:813-538-7880
Mailing Address - Fax:813-538-7880
Practice Address - Street 1:1221 W STRATFORD RD
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-8091
Practice Address - Country:US
Practice Address - Phone:863-453-2500
Practice Address - Fax:863-453-0745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center