Provider Demographics
NPI:1164552378
Name:CENTINELA VALLEY IPA MEDICAL GROUP
Entity Type:Organization
Organization Name:CENTINELA VALLEY IPA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-673-9499
Mailing Address - Street 1:PO BOX 4069
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-0469
Mailing Address - Country:US
Mailing Address - Phone:909-971-6717
Mailing Address - Fax:
Practice Address - Street 1:955 OVERLAND CT FL 2
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-1718
Practice Address - Country:US
Practice Address - Phone:909-971-6717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171W00000X171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty