Healthcare Provider Details

I. General information

NPI: 1073249348
Provider Name (Legal Business Name): PALM MEDICAL CENTER LAKELAND LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 07/28/2022
Certification Date: 07/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11017 N DALE MABRY HWY STE B
TAMPA FL
33618-3873
US

IV. Provider business mailing address

2600 S DOUGLAS RD STE 308
CORAL GABLES FL
33134-6134
US

V. Phone/Fax

Practice location:
  • Phone: 813-337-7402
  • Fax: 813-461-6462
Mailing address:
  • Phone: 813-538-7880
  • Fax: 305-442-1198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SANTIAGO MOISES MARTIN
Title or Position: PRESIDENT OF CENTER OPERATIONS
Credential:
Phone: 305-913-9441