1689800377 NPI number — CENTRELAKE MEDICAL GROUP, INC.

Table of content: (NPI 1689800377)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689800377 NPI number — CENTRELAKE MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRELAKE MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689800377
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3115 E GUASTI RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ONTARIO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91761-7853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-635-0411
Provider Business Mailing Address Fax Number:
909-635-0441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1555 N ORANGE GROVE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POMONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91767-3811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-635-0411
Provider Business Practice Location Address Fax Number:
909-635-0441
Provider Enumeration Date:
06/08/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LAPSI
Authorized Official First Name:
AMAR
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
626-331-6866

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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