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General NPI Number Information
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NPI Number | 1144508458
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Entity Type | Organization
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Legal Business Name | CENTRO MEDICAL GUADALUPE
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Dates
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Enumeration Date | 08/03/2011
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Last Update Date | 08/03/2011
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Provider Practice Location Address
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Address Line | 1220 N MAIN ST
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City | FORT WORTH
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State | TX
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Zip | 76164-9168
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Country | US
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Telephone | 817-378-0777
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Fax | 817-378-9522
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Provider Business Mailing Address
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Address Line | 1220 N MAIN ST
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City | FORT WORTH
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State | TX
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Zip | 76164-9168
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Country | US
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Telephone | 817-378-0777
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. MARYNA LOMBARD
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Credential |
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Telephone | 972-355-1831
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | H4919
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License Number State | TX
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