# PALM MEDICAL CENTER LAKELAND LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1073249348
- **Authorized official:** SANTIAGO MOISES MARTIN (PRESIDENT OF CENTER OPERATIONS)
- **Authorized official phone:** (305) 913-9441

## Contact information

- **Practice address:** 11017 N DALE MABRY HWY STE B, TAMPA, FL 33618-3873
- **Practice address phone:** (813) 337-7402
- **Practice address fax:** (813) 461-6462
- **Mailing address:** 2600 S DOUGLAS RD STE 308, CORAL GABLES, FL 33134-6134
- **Mailing address phone:** (813) 538-7880
- **Mailing address fax:** (305) 442-1198

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208D00000X | General Practice Physician | — | — | Yes |
| 261Q00000X | Clinic/Center | — | — | — |

## Other

- **Enumeration date:** 07/28/2022
- **Last updated:** 07/28/2022

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 016289500 | — | FL |