Provider Demographics
NPI:1144508458
Name:CENTRO MEDICAL GUADALUPE
Entity type:Organization
Organization Name:CENTRO MEDICAL GUADALUPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYNA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOMBARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-355-1831
Mailing Address - Street 1:1220 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76164-9168
Mailing Address - Country:US
Mailing Address - Phone:817-378-0777
Mailing Address - Fax:
Practice Address - Street 1:1220 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76164-9168
Practice Address - Country:US
Practice Address - Phone:817-378-0777
Practice Address - Fax:817-378-9522
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORES MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4919261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care