Healthcare Provider Details

I. General information

NPI: 1932425295
Provider Name (Legal Business Name): CMG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2010
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5608 PGA BLVD SUITE 208
PALM BEACH GARDENS FL
33418-4121
US

IV. Provider business mailing address

5608 PGA BLVD SUITE 208
PALM BEACH GARDENS FL
33418-4121
US

V. Phone/Fax

Practice location:
  • Phone: 561-613-4500
  • Fax:
Mailing address:
  • Phone: 561-613-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME87200
License Number StateFL

VIII. Authorized Official

Name: DR. CARLOS GONZALEZ JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 561-627-0107