Provider Demographics
NPI:1972841088
Name:CENTRAL MEDICO LLC
Entity Type:Organization
Organization Name:CENTRAL MEDICO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARYNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOMBARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-378-0777
Mailing Address - Street 1:1220 N MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76164-9168
Mailing Address - Country:US
Mailing Address - Phone:817-378-0777
Mailing Address - Fax:817-378-9522
Practice Address - Street 1:1220 N MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76164-9168
Practice Address - Country:US
Practice Address - Phone:817-378-0777
Practice Address - Fax:817-378-9522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00214QMedicare PIN