Provider Demographics
NPI:1598926677
Name:CENTENNIAL MEDICAL GROUP
Entity Type:Organization
Organization Name:CENTENNIAL MEDICAL GROUP
Other - Org Name:CENTENNIAL UPRIGHT MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-818-2825
Mailing Address - Street 1:4454 N DECATUR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-5286
Mailing Address - Country:US
Mailing Address - Phone:702-839-1203
Mailing Address - Fax:702-507-0992
Practice Address - Street 1:4640 W CRAIG RD
Practice Address - Street 2:
Practice Address - City:N LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-2743
Practice Address - Country:US
Practice Address - Phone:702-839-1203
Practice Address - Fax:702-507-0992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-20
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV103360OtherMEDICARE P-10