Provider Demographics
NPI:1629718804
Name:CENTIVO CARE
Entity Type:Organization
Organization Name:CENTIVO CARE
Other - Org Name:CENTIVO VIRTUAL PRIMARY CARE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEE
Authorized Official - Middle Name:MEGHAN
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-939-5564
Mailing Address - Street 1:174 W COMSTOCK AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:174 W COMSTOCK AVE STE 100
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-4347
Practice Address - Country:US
Practice Address - Phone:716-939-5564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-29
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care