Provider Demographics
NPI:1881220861
Name:LAKE WORTH MEDICAL CLINIC CORP
Entity Type:Organization
Organization Name:LAKE WORTH MEDICAL CLINIC CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-660-7399
Mailing Address - Street 1:6295 LAKE WORTH RD STE 30
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-3034
Mailing Address - Country:US
Mailing Address - Phone:561-660-7399
Mailing Address - Fax:561-660-7549
Practice Address - Street 1:6295 LAKE WORTH RD STE 30
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-3034
Practice Address - Country:US
Practice Address - Phone:561-377-7006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-21
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty