MEDICARE: CENTERWELL SENIOR PRIMARY CARE (LA) PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207Q00000X	Family Medicine Physician
2	208D00000X	General Practice Physician
3	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1962276956
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTERWELL SENIOR PRIMARY CARE (LA) PC

Provider Business Mailing Address
First Line	:	4700 MILLENIA BLVD STE 650
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32839-6013
Country	:	US
Telephone Number	:	407-447-7120
Fax Number	:

Provider Business Practice Location Address
First Line	:	6404 GROOM RD
Second Line	:
City	:	BAKER
State	:	LA
Zip	:	70714-4364
Country	:	US
Telephone Number	:	225-614-9065
Fax Number	:

Authorized Official
Title or Position	:	SENIOR CREDENTIALING PROFESSIONAL
Name	:	ANGIE MARTINEZ
Credential	:
Telephone Number	:	407-447-7120

Provider Enumeration Date	:	11/09/2023
Last Update Date	:	11/09/2023

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