Basic Information
| Provider Information | |||||||||
| NPI: | 1184247579 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTERWELL SENIOR PRIMARY CARE (NV) PC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CENTERWELL SENIOR PRIMARY CARE-NORTH RAINBOW | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 MILLENIA BLVD STE 650 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328396013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074477120 | ||||||||
| FaxNumber: | 4077700661 | ||||||||
| Practice Location | |||||||||
| Address1: | 3129 N RAINBOW BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891084578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7252208457 | ||||||||
| FaxNumber: | 8337490355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2020 | ||||||||
| LastUpdateDate: | 10/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MARTINEZ | ||||||||
| AuthorizedOfficialFirstName: | ANGIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR CREDENTIALING PROFESSIONAL | ||||||||
| AuthorizedOfficialTelephone: | 4074477120 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTERWELL SENIOR PRIMARY CARE (NV) PC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 250009856 | 05 | NV | MEDICAID | V65959 | 01 | NV | MEDICARE | OTHER |