Provider Demographics
NPI:1164124111
Name:CENTENNIAL MEDICAL GROUP EAST, LLC
Entity Type:Organization
Organization Name:CENTENNIAL MEDICAL GROUP EAST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:TYREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-229-3332
Mailing Address - Street 1:2570 NW EDENBOWER BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6214
Mailing Address - Country:US
Mailing Address - Phone:541-677-7200
Mailing Address - Fax:541-229-3309
Practice Address - Street 1:249 DAKOTA ST
Practice Address - Street 2:
Practice Address - City:SUTHERLIN
Practice Address - State:OR
Practice Address - Zip Code:97479-9908
Practice Address - Country:US
Practice Address - Phone:541-677-7200
Practice Address - Fax:541-229-3309
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTENNIAL MEDICAL GROUP EAST, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty