Provider Demographics
NPI:1447689203
Name:CENTER FOR INDIVIDUALIZED MEDICINE AND AGE MANAGEMENT, INC
Entity type:Organization
Organization Name:CENTER FOR INDIVIDUALIZED MEDICINE AND AGE MANAGEMENT, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OSNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:
Authorized Official - Last Name:DONIS-RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-273-7399
Mailing Address - Street 1:11616 LAKE UNDERHILL RD
Mailing Address - Street 2:STE 205
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-4463
Mailing Address - Country:US
Mailing Address - Phone:407-273-7399
Mailing Address - Fax:407-273-1928
Practice Address - Street 1:11616 LAKE UNDERHILL RD
Practice Address - Street 2:STE 205
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-4463
Practice Address - Country:US
Practice Address - Phone:407-273-7399
Practice Address - Fax:407-273-1928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55637207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty