=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578350062
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLEARMEDICA MEDICAL CENTERS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2025
-----------------------------------------------------
Last Update Date | 04/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6631 S FLORIDA AVE # 3
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33813-3360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-812-4126
-----------------------------------------------------
Fax | 866-611-7057
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5618
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33807-5618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-588-5001
-----------------------------------------------------
Fax | 866-611-7057
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GLORIMAR GONZALEZ SAMOT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 813-588-5001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------