Provider Demographics
NPI:1568515492
Name:CENTENNIAL MEDICAL CLINIC
Entity Type:Organization
Organization Name:CENTENNIAL MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-667-3565
Mailing Address - Street 1:232 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-5525
Mailing Address - Country:US
Mailing Address - Phone:970-667-3565
Mailing Address - Fax:970-667-2343
Practice Address - Street 1:232 W 4TH ST
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-5525
Practice Address - Country:US
Practice Address - Phone:970-667-3565
Practice Address - Fax:970-667-2343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15838207Q00000X
CO22781207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04925087Medicaid
COC92508Medicare PIN