Provider Demographics
NPI:1477919389
Name:LYMPHEDEMA MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:LYMPHEDEMA MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-702-3401
Mailing Address - Street 1:5410 FREDERICKSBURG RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3550
Mailing Address - Country:US
Mailing Address - Phone:210-702-3401
Mailing Address - Fax:
Practice Address - Street 1:5410 FREDERICKSBURG RD STE 102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3550
Practice Address - Country:US
Practice Address - Phone:210-702-3401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine