Healthcare Provider Details

I. General information

NPI: 1396780185
Provider Name (Legal Business Name): MEDICAL CORAL WAY CENTER CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 10/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S MILITARY TRL SUITE C-1
WEST PALM BEACH FL
33415-5720
US

IV. Provider business mailing address

1401 S MILITARY TRL SUITE C
WEST PALM BEACH FL
33415-5720
US

V. Phone/Fax

Practice location:
  • Phone: 561-429-3122
  • Fax: 561-429-3124
Mailing address:
  • Phone: 561-429-3122
  • Fax: 561-429-3124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARIELA CRUZ
Title or Position: PRESIDENT
Credential:
Phone: 561-429-3122