MEDICARE: LWCMDIV, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1427458868
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LWCMDIV, LLC

Provider Business Mailing Address
First Line	:	2150 49TH ST N
Second Line	:	SUITE C
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33710-5237
Country	:	US
Telephone Number	:	727-321-6130
Fax Number	:	727-327-2677

Provider Business Practice Location Address
First Line	:	2150 49TH ST N
Second Line	:	SUITE C
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33710-5237
Country	:	US
Telephone Number	:	727-321-6130
Fax Number	:	727-327-2677

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	WILLIAM A LA TORRE
Credential	:	D.C.
Telephone Number	:	727-321-6130

Provider Enumeration Date	:	09/03/2014
Last Update Date	:	09/03/2014

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