MEDICARE: CENTIVO CARE

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1629718804
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTIVO CARE

Provider Business Mailing Address
First Line	:	174 W COMSTOCK AVE STE 100
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32789-4347
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	174 W COMSTOCK AVE STE 100
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32789-4347
Country	:	US
Telephone Number	:	716-939-5564
Fax Number	:

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	ASHLEE MEGHAN DAVIDSON
Credential	:
Telephone Number	:	716-939-5564

Provider Enumeration Date	:	03/29/2022
Last Update Date	:	12/01/2022

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Directions to “CENTIVO CARE ” Practice Location

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