Provider Demographics
NPI:1659820546
Name:COMMONHEALTH SERVICES CORP.
Entity Type:Organization
Organization Name:COMMONHEALTH SERVICES CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:DE LA CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:407-275-1373
Mailing Address - Street 1:960 MAPLE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-6450
Mailing Address - Country:US
Mailing Address - Phone:407-275-1373
Mailing Address - Fax:
Practice Address - Street 1:733 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-4441
Practice Address - Country:US
Practice Address - Phone:352-435-7214
Practice Address - Fax:352-435-7553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69780208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379673600Medicaid