Provider Demographics
NPI:1619636610
Name:CENTRO MEDICO LLC
Entity Type:Organization
Organization Name:CENTRO MEDICO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOCELIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:239-849-9770
Mailing Address - Street 1:1425 VISCAYA PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-3294
Mailing Address - Country:US
Mailing Address - Phone:239-257-1167
Mailing Address - Fax:
Practice Address - Street 1:1425 VISCAYA PKWY STE 101
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-3294
Practice Address - Country:US
Practice Address - Phone:239-257-1167
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service