Healthcare Provider Details

I. General information

NPI: 1285257667
Provider Name (Legal Business Name): CENTERWELL SENIOR PRIMARY CARE NV P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 S DECATUR BLVD STE 25
LAS VEGAS NV
89103-5857
US

IV. Provider business mailing address

6101 BLUE LAGOON DR STE 200
MIAMI FL
33126-3168
US

V. Phone/Fax

Practice location:
  • Phone: 725-224-6967
  • Fax: 833-749-0357
Mailing address:
  • Phone: 407-447-7120
  • Fax: 407-770-0661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGIE MARTINEZ
Title or Position: SENIOR CREDENTIALING PROFESSIONAL
Credential:
Phone: 407-447-7120