=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619786258
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRUM MEDICAL HOLDING OF BOCA RATON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2025
-----------------------------------------------------
Last Update Date | 01/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21073 POWERLINE RD STE 35
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33433-2306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-266-2929
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9250 NW 36TH ST STE 420
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33178-2775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-266-2929
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | GRACIELA VANESSA VICTORERO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-266-2929
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------