Provider Demographics
NPI:1467944421
Name:LATINO MEDICASL CENTER 111 INC
Entity Type:Organization
Organization Name:LATINO MEDICASL CENTER 111 INC
Other - Org Name:LATINO MEDICASL CENTER 111 INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CODER
Authorized Official - Prefix:
Authorized Official - First Name:ENID
Authorized Official - Middle Name:
Authorized Official - Last Name:LEON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-797-6669
Mailing Address - Street 1:6422 NW 65TH WAY
Mailing Address - Street 2:
Mailing Address - City:PARKLAND
Mailing Address - State:FL
Mailing Address - Zip Code:33067-1503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3670 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33311-1148
Practice Address - Country:US
Practice Address - Phone:954-716-6101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTAX